7支气管哮喘-双语-课件

Asthma

ZhongminQiuDepartmentofRespiratoryMedicineTongjiHospitalofTongjiUniversityAsthma1WhatIsAsthma?

Asthmaisadiseasethatcharacterizedby:AirwayobstructionthatisreversibleeitherspontaneouslyorwithtreatmentchronicairwayinflammationIncreasedairwayresponsivenesstoavarietyofstimuliInflammationcausesrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing,particularlyatnightorearlymorning

WhatIsAsthma?Asthmaisadi2

Epidemiology17-20millionAmericans(6-10%prevalence)1%estimatedprevalenceinmainlandofChina10millionmedicalvisits2millionemergencyvisits0.5millionhospitalization5000deathsannuallyMajorcauseofschoolandworkabsenceAtleast12billionperyear

Increasingburdenforyears Epidemiology17-20million3ImpactOfAsthmaOnPatients

Psychosocial:Poorself-esteemAnxietyaboutasthmaFearofbecomingillatout-doorAnxietyaboutexerciseFearofbeingdifferent

ImpactOfAsthmaOnPatients4DidYouKnow..

Asthmakillspeopleequallyregardlessofseveritylevel1/3ofdeathsareinthosewithmildasthma1/3ofdeathsareinthosewithmoderateasthma1/3ofdeathsareinthosewithsevereasthmaDidYouKnow..Asthmakills5WhatCausesAsthma?Asthmamaybecausedbygenetic,immuneand/orenvironmentalfactors,andisoftenassociatedwitheczemaandallergiesWedonotunderstandallofthecausesofasthmaoritsincreasingprevalenceItboilsdownto“Wejustdon’treallyknowforsure”WhatCausesAsthma?Asthmamay6WhatCausesAsthmaOfthe17millionasthmasufferersintheUS,10Million(approx.60%)haveallergicasthma.3millionofthosearechildrenExposuretocertainallergenstriggerasthmasymptomstobeginExposuretocertainirritantscanalsosetanasthmaepisodeinmotionWhatCausesAsthmaOfthe17m7TriggersandIrritantsTriggersandIrritants8CommonAllergens(Triggers) SeasonalPollensAnimaldandersaliva/urineDustMitesCockroaches/Mice/RatdroppingsandurineMoldSomemedicationsSomeFoods

CommonAllergens(Triggers) S9CommonIrritants(Triggers)ExerciseColdAirChalkDustViral/upperrespiratoryinfectionsAirpollutionTobaccosmokeorsecondhandsmokeChemicalirritantsandstrongsmellsStrongemotionalfeelingsDieselfumesCleaningsuppliesCommonIrritants(Triggers)Exe10AirwayHyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycellrecruitmentandactivationNeuralactivationVirus-infectedepitheliumRV-InducedAirwayInflammationAirwayPlasmaMucusInflammatory11VirusescauseasthmaexacerbationsRVscause~60%ofvirus-inducedexacerbationsofasthmaRVsdirectlyinfectthebronchialairwaysTheresponsetoviralinfectionisshapedbythehost’santiviralresponseRV-InducedAsthmaVirusescauseasthmaexacerbat12Nakano,Y.etal.Chest2002;122:271S-a-275S-aPathophysiologicschemaforthedevelopmentofasthmaNakano,Y.etal.Chest2002;113

TheAllergicReactionTheAllergicReaction14TheAsthmaCascadeTheAsthmaCascade157支气管哮喘-双语-课件16MediatorPhasesEarly-phasereactioncausedbymediatorrelease,usuallypeakswithinanhourafterinitialexposuretotheallergen.Threetofourhoursafteranacuteasthmaepisode,a"late-phasereaction"mayoccurandmaylastupto24hoursMediatorPhasesEarly-phaserea17TheEndResultsOfTheCascade LocalizedmucosaledemainthewallsofthesmallbronchiolesSecretionofthickmucusintothebronchiolarlumens(Clogsandnarrowstheairways)SpasticcontractionofbronchiolarsmoothmuscleTheEndResultsOfTheCascade18NormalBronchioleInflamedBronchiole

withMucus NormalBronchioleInflamed19AirwayObstructionCopyright3MPharmaceuticals2004AirwayObstructionCopyright3M207支气管哮喘-双语-课件21RemodelingPhasesAirwaywallthickening.SubepithelialfibrosisSmoothmusclehyperplasiaandhypertrophyMyofibroblasthyperplasiaMucusmetaplasiaRemodelingPhasesAirwaywallt22Vignola,A.M.etal.Chest2003;123:417S-a-422S-aIncreasedthicknessofthebasementmembrane(arrow),andenhancedandabnormaldepositionoffibronectin,whichisidentifiedbyimmunohistochemistryusingaspecificmonoclonalantibody(dashedarrow),inthebronchialsubmucosaVignola,A.M.etal.Chest2023Increasedthicknessofthebasementmembrane,andenhancedandabnormaldepositionofcollageninthebronchialsubmucosaIncreasedthicknessofthebas24ALotGoingOnBeneathTheSurfaceAirwayinflammationAirflowobstructionBronchialhyperresponsiveness

SymptomsALotGoingOnBeneathTheSur25CommonSymptomsOfAsthmaFrequentcough,especiallyatnightShortnessofbreathorrapidbreathingChesttightnessChestpainWheezingFatigueCommonSymptomsOfAsthmaFrequ26Early

SignsOfAnAsthma“Episode”MildcoughDropinPeakFlowreadingItchy,wateryorglassyeyesItchy,scratchyorsorethroatRunnynoseStomachacheHeadacheSneezingCongestionRestlessnessDarkcirclesundereyesIrritabilityEarlySignsOfAnAsthma“Epis27MeasuresOfAssessment

AndMonitoringTwoAspects:InitialassessmentanddiagnosisofasthmaPeriodicassessmentandmonitoringMeasuresOfAssessment

AndMo28InitialAssessment&

DiagnosisofAsthmaDeterminesThat:PatienthasahistoryorpresenceofepisodicsymptomsofairflowobstructionAirflowobstructionisatleastpartiallyreversibleAlternativediagnosesareexcludedInitialAssessment&

Diagnosi29

MethodsforEstablishing

DiagnosisDetailedmedicalhistoryPhysicalexam:wheezeandrhonchus(rhonchi)SpirometrytodemonstratereversibilityMethodsforEstablishing

Dia30Diagnosisofasthma

Objectivemeasurements>20%diurnalvariationon3daysin

aweekfor2weeksonPEFdiaryorFEV1

15%(and200ml)increaseaftershortactingß2agonistorsteroidtabletsorFEV115%decreaseafter6minutesofrunningexercisehistamineormethacholinechallengeindifficultcasesSymptoms(episodic/variable)wheezeshortnessofbreathchesttightnesscoughSignsnone(common)wheeze–diffuse,bilateral,expiratory(inspiratory)tachypneaHelpfuladditionalinformationpersonal/familyhistoryofasthmaoratopyhistoryofworseningafteraspirin/NSAID,

blockeruserecognisedtriggers–pollens,dust,animals,exercise,viralinfections,chemicals,irritantspatternandseverityofsymptomsandexacerbationsConsiderthediagnosisofasthmainpatientswithsomeorallofthesefeaturesDiagnosisofasthma

Objective31

AsthmaLungAssessment

Spirometry

SpirometryisGoldstandardtoassistinasthmadiagnosisPerformedbeforeandafterbronchodilatordosetolookforairwayobstruction

reversibilityCanalsobedonewithhistamineormethylcholinechallenge,oranexercisechallengeinthecaseofexercise-inducedasthma

AsthmaLungAssessmentSpirom32

IsAirflowObstructionAtLeastPartiallyReversible?Use

spirometrytoestablishairflowobstructionFEV1<80%ofpredictedFEV1/FVC<70%UsespirometrytoestablishreversibilityFEV1increases>15%andatleast200mLafterusingashort-actinginhaledbeta2-agonistIsAirflowObstructionAtLea33PeakExpiratoryFlowVariability

AnanotherwaytoevaluateairwayobstructionThereisthedifferencebetweenthemorningandeveningPEFreadingsPEFreadingstendtobehigherintheeveningthaninthemorningPeakExpiratoryFlowVariabili34PeakFlowMetersPeakFlowMeters35

Differentialdiagnosisof

asthma

SomeofsymptomsofasthmaaresharedwithdiseasesofothersystemsNumerousrelativelycommonlungdiseasesNeedtodifferentiatefrominfectionsandrestrictivelung

disorders,andbetweenlocalandgeneralisedobstructionDifferentialdiagnosesinclude:COPDcardiacdiseaselaryngeal,trachealorlungtumourbronchiectasisforeignbodyinterstitiallungdiseasepulmonaryemboliaspirationvocalcorddysfunctionhyperventilationDifferentialdiagnosisof

ast36AsthmaSeverityLevelsMildIntermittentMildPersistentModeratePersistentSeverePersistentAsthmaSeverityLevelsMildIn37AsthmaSeverityLevelsBySymptomsMildIntermittent-Sx<2days/week Sx<2nights/monthMildPersistent-Sx>2x/weekbut<1x/day Sx>2nights/monthModeratePersistent-Sxeveryday Sx>1night/weekSeverePersistent- ContinualdaytimeSx FrequentSxatnight

AsthmaSeverityLevelsBySymp38MildIntermittentSymptoms£2days/weekwithnighttimesymptoms£2nights/monthAsymptomaticwithnormalpeakflowsbetweenexacerbationsExacerbationsarebrief(hourstoafewdays)PeakFlows³80%predictedwithvariability<20%MildIntermittentSymptoms£239MildPersistentSymptoms>2days/weekbut<1x/daywithnighttimesymptomsgreaterthan2nights/monthExacerbationsmayaffectactivityPeakflow³80%predictedwithvariabilityof<20-30%MildPersistentSymptoms>2da40ModeratePersistentChildislikelytohavedailysymptomsanduserelieverdailyChildiswakingupatleastonceaweekduetoasthmasymptomsPeakflows60-80%ofpredictedwithvariabilityof>30%ActivityisaffectedandexacerbationsmaylastdaysModeratePersistentChildisli41SeverePersistentContinualdaytimesymptomswithfrequentnighttimesymptomsVerylimitedphysicalactivityFrequentexacerbationsPeakflows£60%ofpredictedandvariabilityofmorethan30%TreatmentinvolvesacombinationofmanydrugtherapiesSeverePersistentContinualday42GoalsOfAsthmaTherapyPreventchronicandtroublesomesymptomsMaintain“normal”pulmonaryfunctionMaintainnormalactivitylevels-includingexerciseandotherphysicalactivityMinimizetheneedforemergencyroom/urgentcarevisitsorhospitalizationsGoalsOfAsthmaTherapyPrevent43

GoalsOfAsthmaTherapy

Continued…PreventrecurrentexacerbationsofsymptomsProvideoptimalpharmacotherapywithminimalornoadverseeffectsSatisfythepatient’sandthefamily’sgoalsforasthmacareGoalsOfAsthmaTherapy44

StepwiseApproachTo Asthma TherapyOutcome:BestPossibleResultsReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnController:OnedailymedicationPossiblyaddlongactingbronchodilatorAnti-leukotrienesController:DailyinhaledcorticosteroidDailylongactingbronchodilatorAnti-leukotrieneController:DailyinhaledcorticosteroidDailylongactingbronchodilatorDaily/alternatedayoralcorticosteroidWhencontrolled,reducetherapyMonitorPEF:≥80%PEF:≥80%PEF:<60%STEP1:IntermittentSTEP2:MildPersistentSTEP3:ModeratePersistentSTEP4:SeverePersistentStepdownOutcome:ControlofAsthmaPEF:60-80% StepwiseApproachToOutcome:45BronchodilatorsRelaxingbronchialsmoothmuscletoopenuptheairway.Anti-inflammatoryagentsInhibitingthedevelopmentofairwayinflammationandstoppingongoinginflammation.Incombination,treatandpreventreversibleairwayobstructionandairwayhyperresponsiveness,relievethesymptomanddecreasetheexacerbation.CommonDrugsforAsthmaBronchodilatorsCommonDrugsfo46Long-termcontrolmedication(Controller)CorticosteriodsCromolyn/nedocromilLongactingb2agonists(LABA)LeukotrienemodifierQuickreliefmedication(Rescuer)Short-actingb2agonistsTheophyllineAnticholinergicsSystemicCorticosteriodsCommonDrugsforAsthmaLong-termcontrolmedication(477支气管哮喘-双语-课件48Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaInhaledshortactingß2agonistasrequiredStepwisemanagementof

asthma49Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyAddinhaledsteroid200-800mcg/day*400mcgisanappropriatestartingdoseformanypatientsStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStepwisemanagementof

asthma50Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep3:Add-ontherapys1.Addinhaledlong-actingß2agonist(LABA)2.Assesscontrolofasthma:good

responsetoLABA–continueLABAbenefitfromLABAbutcontrolstillinadequate–continueLABAandincreaseinhaledsteroiddoseto800mcg/day*(ifnotalreadyonthisdose)noresponsetoLABA–stopLABAandincreaseinhaledsteroidto

800mcg/day*.Ifcontrolstillinadequate,institutetrialofothertherapies

(e.g.leukotrienereceptorantagonistorSRtheophylline)Step2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStepwisemanagementof

asthma51Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStep3:Add-ontherapyStep4:PersistentpoorcontrolConsidertrialsof:increasinginhaledsteroidupto2000mcg/day*additionoffourthdrug(e.g.leukotrienereceptorantagonist,SRtheophylline,ß2agonisttablet)Stepwisemanagementof

asthma52Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStep3:Add-ontherapyStep4:PersistentpoorcontrolStep5:ContinuousorfrequentuseoforalsteroidsUsedailysteroidtabletinlowestdoseprovidingadequatecontrolMaintainhighdoseinhaledsteroidat2000mcg/day*ConsiderothertreatmentstominimisetheuseofsteroidtabletsReferpatientforspecialistcareStepwisemanagementof

asthma53Stepwisemanagementof

asthmainadultsStep1:MildintermittentasthmaStep5:ContinuousorfrequentuseoforalsteroidsStep4:PersistentpoorcontrolStep3:Add-ontherapyStep2:RegularpreventertherapyStepwisemanagementof

asthma54OxygentherapyandmechanicalventilationShort-actingb2agonistsAminophyllineAnticholinergicsCorticosteriods

ManagementforAcuteExacerbation

ofAsthmaOxygentherapyandmechanical55SameasacuteexacerbationofasthmaFluidinfusionModificationofacidosisAntibioticsMaintenanceofelectrolytebalanceResolutionofcomplications

ManagementforStatusAsthmaticsSameasacuteexacerbationof56Asthma

ZhongminQiuDepartmentofRespiratoryMedicineTongjiHospitalofTongjiUniversityAsthma57WhatIsAsthma?

Asthmaisadiseasethatcharacterizedby:AirwayobstructionthatisreversibleeitherspontaneouslyorwithtreatmentchronicairwayinflammationIncreasedairwayresponsivenesstoavarietyofstimuliInflammationcausesrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing,particularlyatnightorearlymorning

WhatIsAsthma?Asthmaisadi58

Epidemiology17-20millionAmericans(6-10%prevalence)1%estimatedprevalenceinmainlandofChina10millionmedicalvisits2millionemergencyvisits0.5millionhospitalization5000deathsannuallyMajorcauseofschoolandworkabsenceAtleast12billionperyear

Increasingburdenforyears Epidemiology17-20million59ImpactOfAsthmaOnPatients

Psychosocial:Poorself-esteemAnxietyaboutasthmaFearofbecomingillatout-doorAnxietyaboutexerciseFearofbeingdifferent

ImpactOfAsthmaOnPatients60DidYouKnow..

Asthmakillspeopleequallyregardlessofseveritylevel1/3ofdeathsareinthosewithmildasthma1/3ofdeathsareinthosewithmoderateasthma1/3ofdeathsareinthosewithsevereasthmaDidYouKnow..Asthmakills61WhatCausesAsthma?Asthmamaybecausedbygenetic,immuneand/orenvironmentalfactors,andisoftenassociatedwitheczemaandallergiesWedonotunderstandallofthecausesofasthmaoritsincreasingprevalenceItboilsdownto“Wejustdon’treallyknowforsure”WhatCausesAsthma?Asthmamay62WhatCausesAsthmaOfthe17millionasthmasufferersintheUS,10Million(approx.60%)haveallergicasthma.3millionofthosearechildrenExposuretocertainallergenstriggerasthmasymptomstobeginExposuretocertainirritantscanalsosetanasthmaepisodeinmotionWhatCausesAsthmaOfthe17m63TriggersandIrritantsTriggersandIrritants64CommonAllergens(Triggers) SeasonalPollensAnimaldandersaliva/urineDustMitesCockroaches/Mice/RatdroppingsandurineMoldSomemedicationsSomeFoods

CommonAllergens(Triggers) S65CommonIrritants(Triggers)ExerciseColdAirChalkDustViral/upperrespiratoryinfectionsAirpollutionTobaccosmokeorsecondhandsmokeChemicalirritantsandstrongsmellsStrongemotionalfeelingsDieselfumesCleaningsuppliesCommonIrritants(Triggers)Exe66AirwayHyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycellrecruitmentandactivationNeuralactivationVirus-infectedepitheliumRV-InducedAirwayInflammationAirwayPlasmaMucusInflammatory67VirusescauseasthmaexacerbationsRVscause~60%ofvirus-inducedexacerbationsofasthmaRVsdirectlyinfectthebronchialairwaysTheresponsetoviralinfectionisshapedbythehost’santiviralresponseRV-InducedAsthmaVirusescauseasthmaexacerbat68Nakano,Y.etal.Chest2002;122:271S-a-275S-aPathophysiologicschemaforthedevelopmentofasthmaNakano,Y.etal.Chest2002;169

TheAllergicReactionTheAllergicReaction70TheAsthmaCascadeTheAsthmaCascade717支气管哮喘-双语-课件72MediatorPhasesEarly-phasereactioncausedbymediatorrelease,usuallypeakswithinanhourafterinitialexposuretotheallergen.Threetofourhoursafteranacuteasthmaepisode,a"late-phasereaction"mayoccurandmaylastupto24hoursMediatorPhasesEarly-phaserea73TheEndResultsOfTheCascade LocalizedmucosaledemainthewallsofthesmallbronchiolesSecretionofthickmucusintothebronchiolarlumens(Clogsandnarrowstheairways)SpasticcontractionofbronchiolarsmoothmuscleTheEndResultsOfTheCascade74NormalBronchioleInflamedBronchiole

withMucus NormalBronchioleInflamed75AirwayObstructionCopyright3MPharmaceuticals2004AirwayObstructionCopyright3M767支气管哮喘-双语-课件77RemodelingPhasesAirwaywallthickening.SubepithelialfibrosisSmoothmusclehyperplasiaandhypertrophyMyofibroblasthyperplasiaMucusmetaplasiaRemodelingPhasesAirwaywallt78Vignola,A.M.etal.Chest2003;123:417S-a-422S-aIncreasedthicknessofthebasementmembrane(arrow),andenhancedandabnormaldepositionoffibronectin,whichisidentifiedbyimmunohistochemistryusingaspecificmonoclonalantibody(dashedarrow),inthebronchialsubmucosaVignola,A.M.etal.Chest2079Increasedthicknessofthebasementmembrane,andenhancedandabnormaldepositionofcollageninthebronchialsubmucosaIncreasedthicknessofthebas80ALotGoingOnBeneathTheSurfaceAirwayinflammationAirflowobstructionBronchialhyperresponsiveness

SymptomsALotGoingOnBeneathTheSur81CommonSymptomsOfAsthmaFrequentcough,especiallyatnightShortnessofbreathorrapidbreathingChesttightnessChestpainWheezingFatigueCommonSymptomsOfAsthmaFrequ82Early

SignsOfAnAsthma“Episode”MildcoughDropinPeakFlowreadingItchy,wateryorglassyeyesItchy,scratchyorsorethroatRunnynoseStomachacheHeadacheSneezingCongestionRestlessnessDarkcirclesundereyesIrritabilityEarlySignsOfAnAsthma“Epis83MeasuresOfAssessment

AndMonitoringTwoAspects:InitialassessmentanddiagnosisofasthmaPeriodicassessmentandmonitoringMeasuresOfAssessment

AndMo84InitialAssessment&

DiagnosisofAsthmaDeterminesThat:PatienthasahistoryorpresenceofepisodicsymptomsofairflowobstructionAirflowobstructionisatleastpartiallyreversibleAlternativediagnosesareexcludedInitialAssessment&

Diagnosi85

MethodsforEstablishing

DiagnosisDetailedmedicalhistoryPhysicalexam:wheezeandrhonchus(rhonchi)SpirometrytodemonstratereversibilityMethodsforEstablishing

Dia86Diagnosisofasthma

Objectivemeasurements>20%diurnalvariationon3daysin

aweekfor2weeksonPEFdiaryorFEV1

15%(and200ml)increaseaftershortactingß2agonistorsteroidtabletsorFEV115%decreaseafter6minutesofrunningexercisehistamineormethacholinechallengeindifficultcasesSymptoms(episodic/variable)wheezeshortnessofbreathchesttightnesscoughSignsnone(common)wheeze–diffuse,bilateral,expiratory(inspiratory)tachypneaHelpfuladditionalinformationpersonal/familyhistoryofasthmaoratopyhistoryofworseningafteraspirin/NSAID,

blockeruserecognisedtriggers–pollens,dust,animals,exercise,viralinfections,chemicals,irritantspatternandseverityofsymptomsandexacerbationsConsiderthediagnosisofasthmainpatientswithsomeorallofthesefeaturesDiagnosisofasthma

Objective87

AsthmaLungAssessment

Spirometry

SpirometryisGoldstandardtoassistinasthmadiagnosisPerformedbeforeandafterbronchodilatordosetolookforairwayobstruction

reversibilityCanalsobedonewithhistamineormethylcholinechallenge,oranexercisechallengeinthecaseofexercise-inducedasthma

AsthmaLungAssessmentSpirom88

IsAirflowObstructionAtLeastPartiallyReversible?Use

spirometrytoestablishairflowobstructionFEV1<80%ofpredictedFEV1/FVC<70%UsespirometrytoestablishreversibilityFEV1increases>15%andatleast200mLafterusingashort-actinginhaledbeta2-agonistIsAirflowObstructionAtLea89PeakExpiratoryFlowVariability

AnanotherwaytoevaluateairwayobstructionThereisthedifferencebetweenthemorningandeveningPEFreadingsPEFreadingstendtobehigherintheeveningthaninthemorningPeakExpiratoryFlowVariabili90PeakFlowMetersPeakFlowMeters91

Differentialdiagnosisof

asthma

SomeofsymptomsofasthmaaresharedwithdiseasesofothersystemsNumerousrelativelycommonlungdiseasesNeedtodifferentiatefrominfectionsandrestrictivelung

disorders,andbetweenlocalandgeneralisedobstructionDifferentialdiagnosesinclude:COPDcardiacdiseaselaryngeal,trachealorlungtumourbronchiectasisforeignbodyinterstitiallungdiseasepulmonaryemboliaspirationvocalcorddysfunctionhyperventilationDifferentialdiagnosisof

ast92AsthmaSeverityLevelsMildIntermittentMildPersistentModeratePersistentSeverePersistentAsthmaSeverityLevelsMildIn93AsthmaSeverityLevelsBySymptomsMildIntermittent-Sx<2days/week Sx<2nights/monthMildPersistent-Sx>2x/weekbut<1x/day Sx>2nights/monthModeratePersistent-Sxeveryday Sx>1night/weekSeverePersistent- ContinualdaytimeSx FrequentSxatnight

AsthmaSeverityLevelsBySymp94MildIntermittentSymptoms£2days/weekwithnighttimesymptoms£2nights/monthAsymptomaticwithnormalpeakflowsbetweenexacerbationsExacerbationsarebrief(hourstoafewdays)PeakFlows³80%predictedwithvariability<20%MildIntermittentSymptoms£295MildPersistentSymptoms>2days/weekbut<1x/daywithnighttimesymptomsgreaterthan2nights/monthExacerbationsmayaffectactivityPeakflow³80%predictedwithvariabilityof<20-30%MildPersistentSymptoms>2da96ModeratePersistentChildislikelytohavedailysymptomsanduserelieverdailyChildiswakingupatleastonceaweekduetoasthmasymptomsPeakflows60-80%ofpredictedwithvariabilityof>30%ActivityisaffectedandexacerbationsmaylastdaysModeratePersistentChildisli97SeverePersistentContinualdaytimesymptomswithfrequentnighttimesymptomsVerylimitedphysicalactivityFrequentexacerbationsPeakflows£60%ofpredictedandvariabilityofmorethan30%TreatmentinvolvesacombinationofmanydrugtherapiesSeverePersistentContinualday98GoalsOfAsthmaTherapyPreventchronicandtroublesomesymptomsMaintain“normal”pulmonaryfunctionMaintainnormalactivitylevels-includingexerciseandotherphysicalactivityMinimizetheneedforemergencyroom/urgentcarevisitsorhospitalizationsGoalsOfAsthmaTherapyPrevent99

GoalsOfAsthmaTherapy

Continued…PreventrecurrentexacerbationsofsymptomsProvideoptimalpharmacotherapywithminimalornoadverseeffectsSatisfythepatient’sandthefamily’sgoalsforasthmacareGoalsOfAsthmaTherapy100

StepwiseApproachTo Asthma TherapyOutcome:BestPossibleResultsReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnController:OnedailymedicationPossiblyaddlongactingbronchodilatorAnti-leukotrienesController:DailyinhaledcorticosteroidDailylongactingbronchodilatorAnti-leukotrieneController:DailyinhaledcorticosteroidDailylongactingbronchodilatorDaily/alternatedayoralcorticosteroidWhencontrolled,reducetherapyMonitorPEF:≥80%PEF:≥80%PEF:<60%STEP1:IntermittentSTEP2:MildPersistentSTEP3:ModeratePersistentSTEP4:SeverePersistentStepdownOutcome:ControlofAsthmaPEF:60-80% StepwiseApproachToOutcome:101BronchodilatorsRelaxingbronchialsmoothmuscletoopenuptheairway.Anti-inflammatoryagentsInhibitingthedevelopmentofairwayinflammationandstoppingongoinginflammation.Incombination,treatandpreventreversibleairwayobstructionandairwayhyperresponsiveness,relievethesymptomanddecreasetheexacerbation.CommonDrugsforAsthmaBronchodilatorsCommonDrugsfo102Long-termcontrolmedication(Controller)CorticosteriodsCromolyn/nedocromilLongactingb2agonists(LABA)LeukotrienemodifierQuickreliefmedication(Rescuer)Short-actingb2agonistsTheophyllineAnticholinergicsSystemicCorticosteriodsCommonDrugsforAst