Asthma Ghanaian Guideline Flashcards
Asthma is defined by GINA as
Heterogenous disease characterized by chronic inflammation
The chronic airway inflammation in asthma is associated with
Airway hyper-responsiveness that leads to recurrent episodes of wheeze , difficulty in breathing, chest tightness and cough
Asthma is associated with reversible
Airway obstruction that could resolve Spontaneously or with treatment
Asthma related mortality occurs more frequently in
Adults compared to children per WHO report in 2020
Factors associated with asthma deaths are
Previous admission to intensive care unit
# Severe asthma necessitating chronic oral corticosteroids
#Poor daily asthma symptom control with excessive use of SABA (1.4 canisters per month)
#Abnormal forced expiratory volume in 1 second (FEV1)
#Frequent emergency department visits
#Low socioeconomic status
#Family dysfunction
#Patient psychological problems
Asthma is the result of
An interplay between genetic and environmental factors
Atopy is a genetic tendency to
Develop allergic conditions in response to common environmental allergens
The strongest risk factor for the development of asthma
Atopy
Airway hyper-responsiveness is defined as
Excessive reactivity or narrowing of the airway in response to broncho-constrictive
Which other genetic aetiology is closely related to atopy
Airway hyper-responsiveness
Examples of environmental factors include
Indoor allergens ( house dust mites, cockroaches)
#Air pollutants
#Respiratory viruses
#Diet
#Endotoxins
#Seasonal outdoor allergens ( grass, pollens ,molds, animal dander )
Patients with atopic /allergic asthma tend to have positive family history of allergic diseases such as
A)Rhinitis
Eczema
Urticarial
B)And develop asthma in early childhood
C) They are more likely to have peripheral eosinophilia or raised serum IgE levels
D) Positive skin prick test to intradermal injection of allergens
The non-atopic/ non- allergic asthma symptoms are triggered by non allergic factors such as
Stress
Cold
Dry air
Anxiety
Viruses
In adults, occupational exposures to organic and inorganic chemicals could lead to
Development of occupational asthma
In childhood, there is a male preponderance of asthma, as well as asthma related hospital admissions in the pre-pubertal ages . However, after puberty, asthma is more prevalent and severe in
Females and this has been associated with hormonal changes and gender specific environmental exposures
Role of diet in the aetiology of Asthma
Low intake of
# fruits and vegetables
# Dairy fats
#Vitamin C
#Vitamin E
Although not scientifically substantiated , it is believed that infants with shorter periods of breastfeeding (less than 6 months) have
Increased risk of developing asthma
What has been shown to be a risk factor as well as a disease modifier for asthma in both children and adults based on longitudinal studies
Obesity
Weight gain in pregnancy could be associated with
15-30% risk of child developing asthma
According to the hygiene hypothesis, exposure to some germs and bacterial endotoxins helps
Mature the young child’s immune response this protecting against asthma and other allergic diseases
The hygienes hypothesis is supported by
Longitudinal
Epidemiological studies
The hygiene hypothesis explain the
Increased prevalence of asthma in urban dwellings compared to rural settings
Children with asthma from lower socioeconomic backgrounds are at increased risk of being exposed to
Indoor( house dust mite, cockroaches)
Outdoor(biomass fuel, urban pollution) allergens due to poor housing conditions which could exacerbate background asthma symptoms
Exposure to environmental tobacco smoking increases the risk of
Childhood Asthma
Cardinal features which contribute to the pathophysiology of asthma are
Airway inflammation
#Airway hyper-responsiveness
#Bronchial smooth muscle constriction
#Increased mucus production
#Bronchial airway remodeling
Airway inflammation involves inflammatory cells such as eosinophils and mast cells which
Release mediators of inflammation
The mediators of inflammation in asthma
Induce goblet cells in the airway mucous membrane to produce mucus
#Induce airway smooth muscle contraction leading to narrowing of the airway
# The airway inflammation also leads to bronchial hyper-responsiveness which make people with asthma vulnerable to environmental triggers
Two main pathways in the pathophysiology of asthma
Immunologic( allergic/atopic) pathway
#Non-immunologic (non-allergic /non-atopic) pathway
Patients with atopic asthma phenotype are likely to have
T helper 2 lymphocytes and IgE mediated immune response to allergens leading to an exaggerated production of inflammatory mediators
The immunologic response is characterized by
Acute(immediate) and late phase reactions with the late phase responsible for the chronic and persistent effect of allergic inflammation
Clinical features of Asthma
Recurrent symptoms of
#Wheeze
#Cough
#Shortness of breath
#Chest tightness which vary over time and intensity
Cough variant Asthma
Wheeze is present with recurrent cough
Clinical features that reduce likelihood of asthma and suggest alternative diagnosis
Chronic cough with no associated wheezing or breathlessness
Transient Wheeze
Wheezing episodes which begin in the first three years of life and may be associated with respiratory tract infections but cease by age six
Persistent wheeze is
Wheezing that begins in the first three years of life and persist beyond six years
Late onset wheeze is
Wheezing episodes that begin after age six
Episodic Viral Wheeze is wheezing
High usually occurs in association with a common cold. There is no wheeze outside episodes of the upper respiratory tract infections
Features suggestive of asthma in pre-school children
Pattern - episodic pattern together with other respiratory symptoms
# Reversibility
#
Investigations for asthma appropriate for pre-school children
Modified bronchodilator response test
Investigations for asthma appropriate for pre-school children
Modified bronchodilator response test
Investigations for asthma appropriate for pre school children
Modified bronchodilator response test
#Allergy test( Skin prick test can be performed in children over age three)
#Plain chest X ray
NB: a positive skin prick test will support underlying atopy . However , a negative test does not rule out asthma
Investigations performed to diagnose asthma in adults and children six years and older
Pulmonary Function Tests
#Bronchial challenge Test ( Bronchoprovocative test)
#Fractional exhaled nitric oxide
# Other supporting investigations that may help in the diagnosis of asthma like blood and sputum eosinophil count
The ratio of FEV1 over FVC indicates airway obstruction if it is
Less than 0.7 in an adult or less than 0.9 in a child 6 years and over
The ratio of FEV1 and forced vital capacity (FVC) indicates airway obstruction if it is
Less than 0.7 in an adult or less than 0.9 in a child 6 years and over
The goal of Pulmonary Function Test in asthma diagnosis is
Document reversible expiratory airflow limitation or obstruction. This is done with Spirometry and Peak Expiratory Flow Rate measurement
Spirometry is more accurate and gives reproducible results than the PEFR and is preferred for the
Diagnosis of Asthma
Pulmonary Function Test is performed in what age group
6 years and above
Normal spirometry result(> 0.70-0.80 in healthy adults and > 90 in children) does not exclude the diagnosis of asthma as patients may be
Asymptomatic during the period of testing
Reversibility in airflow obstruction is confirmed when there is an increase in
Baseline FEV1 greater than 12% and/ or 200ml after administration of 200 to 400 micrograms of inhaled salbutamol. Reversibility is confirmed using a peak expiratory flow meter when baseline PEFR measurements increases by more than 20% after inhalation of 200-400 micrograms of salbutamol or after a 2 week course of oral prednisolone
Bronchial challenge test is performed in adults only where a fall in FEV1 from baseline of greater or equal to
20% after nebulization with standard incremental doses of methacholine or histamine is confirmatory of asthma
Fractional exhaled nitric oxide measurement is used in diagnosis of asthma when
Spirometry is inconclusive
Fractional exhaled nitric oxide level of
40 parts per billion or more is regarded as suggestive of asthma in adults while in children while a value of 35ppb or more suggestive of asthma
Blood eosinophilia greater than 4% or 300-400/microliter or sputum eosinophil> 3% supports diagnosis of
Asthma
Occupational Asthma is caused by workplace exposure to
Allergic and non-allergic stimuli
There are two main forms of Occupational Asthma
Sensitizer induced
#Irritant induced
Sensitizer induced Asthma is caused by
Allergic stimuli and develops after a latency period between the first exposure and the onset of symptoms . Results from exposure to a substance that the workplace
Irritant induced Occupational Asthma
Caused by exposure to non-allergic irritants at the work place
Uncontrolled Asthma is usually due to
Lapses in quality of care
#Inadequate use of steroids
#Reliance on bronchodilators
Good control of symptoms means a patient
Experiences no more than 1 daytime symptom per month
#Has no acute exacerbations in the past month
#Has no night time symptoms which interfere with sleep being able to participate in daily activities including physical exercise and sports
What medication is given to reduce the risk of serious exacerbations
Inhaled ICS
According to GINA, what medication is given as reliever therapy
ICS Formoterol or SABA+ ICS
SABA only treatment is not recommended by GINA as
It increases the risk of exacerbations and that adding any ICS significantly reduces the risk
Treatment with LABA only is not
Recommended
Budesonide Formoterol is prescribed as
Reliever therapy
Maintenance therapy or
As needed only
Maximum recommended total dose of Formoterol Budesonide is
54mcg of Formoterol (12 inhalations of budesonide Formoterol)
Beclomethasone Formoterol is prescribed in
Maintenance therapy
Reliever therapy
The maximum recommended total dose of Beclomethasone Formoterol in one day is
36mcg Formoterol (8 inhalations of Beclomethasone Formoterol)
Fluticasone salmeterol is not recommended for maintenance and reliever therapy due to
Slower onset of action of salmeterol than Formoterol
According to GINA, How many steps are there in asthma therapy
5 steps
According to GINA, how many tracks are there
2
Preferred Track
Alternative Track
Step 1 approach to Asthma therapy in GINA is for when
Symptom less than twice a month
Controller in the preferred track for step 1 in GINA is
As needed low dose ICS Formoterol
Step 2 approach to Asthma therapy in GINA is for
Symptom twice a month or more but less than 4-5 days a week
Controller in Preferred track for step 2
As needed low dose ICS Formoterol
Step 3 approach in GINA is for
Symptoms most days or waking with asthma
Controller for step 3 in preferred track is
Daily low dose ICS Formoterol
Step 4 approach in GINA is for
Daily symptoms or waking with asthma once a week or more and low lung function
Controller for step 4 in preferred track is
Daily medium dose ICS Formoterol
Controller in step 5 is
Refer to a pulmonologist or specialist
High dose ICS LABA
LAMA may be added on
Add on therapy for preferred track is
Leukotriene antagonists
Montelukast
Pranlukast
Zafirlukast
Benefits of Leukotriene antagonists
Additional bronchodilator effect
#Improve Lung function
#Reduce cough
#Airway inflammation
#Acute exacerbation
#Reduce symptoms of allergic comorbidities
Leukotriene antagonists are rarely associated with
Neuropsychiatric side effects especially in children such as hallucinations, hence should be used with caution
Controller used in step 1 for alternative track is
ICS + SABA as needed
Controller used in step 2 for alternative track is
Daily low dose ICS
Controller used in step 3 for alternative track is
Daily low dose ICS LABA
Controller used in step 4 for alternative track is
Daily medium /high dose maintenance ICS-LABA
Add on therapy in alternative track starting at step 2 upwards is
Leukotriene antagonists
Reliever in preferred track is
As needed low dose ICS Formoterol
Reliever in Alternative track is
As needed SABA
Anti-immunoglobulin E (e.g Omalizumab ) may be used in patients with
Severe persistent allergic asthma who are receiving oral corticosteroids and moderate to high dose ICS/LABA.
How is Omalizumab given
Subcutaneous injection every 2 -4 weeks and the dosage depends on serum IgE and patient’s weight.
It may be used in patients who are >= 6 years old.
Reliever in children less than 6 years is
SABA because Steroids are avoided due to side effects
Controller medication used in children 11 years and below is
ICS alone in < 6 years
> 6 years ICS alone or ICS LABA
Role is written asthma action plan
To help the patient become more involved in their management, recognize symptoms early and respond appropriately
Asthma action plan is a w written individualized worksheet that
Shows an individual with asthma the steps to take to keep the condition from getting worse
Acute asthma exacerbations are episodes of
Worsening symptoms (shortness of breath, wheezing,chest tightness and cough) and or decline in lung function compared to an individual’s usual status that is often sufficient to warrant a change in treatment of the patient
Asthma exacerbation may also be known as
Flare-up
Asthma attack
Acute asthma
Asthma exacerbation is marked by the
Onset of acute airway inflammation when a patient is exposed to a trigger or may represent worsening of chromic airway inflammation
In asthma exacerbation, we give oxygen if SPO2 is below
94%
After giving oxygen in acute exacerbation in asthma, what is given next
SABA by MDI or nebulization depending on severity
#Consider Ipratropium bromide in those not responding to SABA alone
#Give corticosteroids within 1 hour
Bronchodilators are administered at intervals of
20 minutes for up to 1 hour initially until the patient has adequate response in asthma exacerbation
Dose of IV magnesium sulphate is
1.2-2g slowly over 20 minutes (25-50mg/kg, maximum 2g in children)
Recommended dose of IV Aminophylline is
5mg/kg as a bolus over 5 minutes followed with infusion given per kg body weight
IV Aminophylline should be used with caution and
Patient’s pulse and or electrocardiogram must be monitored for possible arrhythmias
IV salbutamol and adrenaline (SC or IV) may be used in
Severe asthma under specialist care
Corticosteroids used in asthma emergency
Oral Prednisolone
IV hydrocortisone
Oral Prednisolone is preferred to IV hydrocortisone because
Longer duration of action
Oral route of administration is easier
IV hydrocortisone is administered to patients who are unable to take oral Prednisolone for reasons like
Vomiting
Impaired consciousness
Patient not wanting to take oral Prednisolone
Side effects of steroids
Sleep disturbances
#Increased appetite
#Gastroesohageal reflux
#Mood changes
Patient is discharged if
Symptoms improved and patient is stable for at least 4 hours after the last dose of SABA
#SPO2 > 94% on room air for at least 12 hours
#PEFR> 75% of personal best or predicted
#Good home support is assured
Management of mild allergic rhinitis
Intranasal corticosteroid
Management of moderate allergic rhinitis
Intranasal steroids
Nasal decongestants (nasal saline drops)
Oral antihistamine
Severe allergic rhinitis
Combination therapy with
Inhaled steroids
Oral antihistamines
LTRA
Nasal decongestants
