asthma seminar updated 2024 black lion.pptx

Asthma

1. Bronchial asthma Presenter: Dr. Bisrat Alemayehu (IMR - 2) Moderator : Dr. Amsalu Bekele (Consultant internist & PCCM Subspecialist ) July 2,2024 1 7/2/2024 dr bisrat

2. Outline Definition Epidemiology Pathophysiology Clinical features Diagnosis Treatment Evidences for 2024 GINA updates Asthma remission 2 7/2/2024 dr bisrat

3. Definition GINA 2024 “Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation” 3 7/2/2024 dr bisrat

4. Epidemiology The global burden of asthma in 2017–18 was assessed by the Global Asthma Network in 135 countries using standardized methods (similar to the International Study of Asthma and Allergies in Childhood study ). They found that asthma affects approximately 339 million people, causes approximately 1000 deaths per day, and is in the top 20 causes of years of life with disability 7/2/2024 dr bisrat 4

5. Cont.. The prevalence in US is estimated at 25 million based on data from NHIS A rising prevalence in developing countries which is associated with increased urbanization with increase in the prevalence of atopy and other allergic diseases According to 2015 GBD estimates, over 80% of global asthma deaths occur in LMIC 7/2/2024 dr bisrat 5

6. In Ethiopia .. 6 Ethiopia NCDI Commission Report, November 2018 7/2/2024 dr bisrat

7. ICS = 58.3%, ICS/LABA = 10.5% , no ICS = 32.2% Only 44/182 (24.2%) subjects had well-controlled asthma 58/182 (31%) were not using controller medications and 62/182 (34.6%) had improper inhaler technique Variables found to be associated with uncontrolled asthma include: Incorrect inhalation technique (OR 3.05, 1.58-5.90) Longer duration of asthma (>= 21 year) (OR 3.0,1.08-8.33) Asthma exacerbation in the last 12 months (OR 2.50, 1.40-4.60) Use of biomass fuel for cooking (OR 1.99,1.06-3.72). 7 7/2/2024 dr bisrat

8. Summary of the findings: - 11 studies, 1388 patients included - 45% uncontrolled asthma - Predictors of uncontrolled asthma: - Incorrect inhalation techniques - Frequent SABA use - Presence of co morbidities - Use of oral corticosteroids - Irregular follow-up 8 7/2/2024 dr bisrat

9. Mortality GBD report estimates that asthma accounts for 240000 deaths per year worldwide Age standardized death rates from asthma decreased substantially in most countries Higher rates have been reported for african americans than for white americans 7/2/2024 dr bisrat 9

10. Risk factors Allergy :-The strongest risk factor for asthma is a family history of atopic disease, which increases the risk of developing asthma by 3-4 fold Respiratory Viral Infections Atypical Bacterial Infections Air Pollution Other Early Life Factors Occupational Exposures 7/2/2024 dr bisrat 10

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12. Histopathology of asthma Airway remodeling, abnormal deposition of collagen in the subepithelium and changes in structural cells such as goblet cells, submucosal gland cells, smooth muscle cells, and blood vessel cells 7/2/2024 dr bisrat 12

13. Pathophysiology Mucus production Airflow obstruction Airway hyperresponsivesness Airway inflammation Susceptible individual Activation of inflammatory mediators 13 7/2/2024 dr bisrat

14. Subgroups of CD4 + T cells 14 7/2/2024 dr bisrat

15. thymic stromal lymphopoietin (TSLP) Type 2 innate lymphoid cells (ILC2s) 7/2/2024 dr bisrat 15

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18. Phenotyping asthma heterogeneity CELLULAR PHENOTYPES ( 1) eosinophilic (often defined as >2–3% in induced sputum ), ( 2) neutrophilic (>60–75%), ( 3) mixed eosinophilic and neutrophilic, and ( 4) paucigranulocytic asthma, which lacks observable inflammatory cells. 7/2/2024 dr bisrat 18

19. Molecular phenotypes ( endotypes ) T2-High vs T2-Low Asthma 7/2/2024 dr bisrat 19

20. Clinical Phenotypes Allergic asthma commences in childhood and is associated with allergic disease eczema, allergic rhinitis, or food or drug allergy Eosinophilic airway and respond to ICS Non-allergic asthma : The cellular profile of the sputum of these patients may be neutrophilic, eosinophilic or contain only a few inflammatory cells. less responsive to ICS 7/2/2024 dr bisrat 20

21. Cont.. Adult-onset (late-onset) asthma More in women adults Non allergic and respond less to steroids Asthma with persistent airflow limitation 7/2/2024 dr bisrat 21

22. Clinical manifestation Wheezing, dyspnea, coughing, chest tightness Worse at night, typically awaken early morning Vary over time and in intensity Episodic flare ups Tenacious mucus that’s difficult to expectorate Unable to speak in full sentences RR>25/min PR>110/min Peak flow <50% predicted best Accessory muscle use Sign of severe asthma 22 7/2/2024 dr bisrat

23. Clinical manifestation Silent chest-no wheezing or air entry Cyanosis/feeble or no respiratory effort bradycardia , hypotension Exhausted, confused or unconscious Severe, life-threatening attack refractory to usual treatment where patient poses risk for respiratory failure Causes of status asthmaticus include Viral illnesses Ingestion of NSAIDs , of -adrenergic blockers Environmental pollutants or allergen exposure Abrupt discontinuation of drug therapy Abuse of aerosol medication Life threatening asthma Status asthmaticus 23 7/2/2024 dr bisrat

24. Diagnosis and evaluation Approach Primary Assessment tools: For making diagnosis of Asthma Presumptive diagnosis : Based on History Confirmation Pulmonary function testing Demonstration of airway hyperresponsiveness Adjunctive Assessment tools: Identify precipitants & underlying mechanisms Eosinophil Counts Exhaled Nitric Oxide Sputum examination IgE, Skin Tests & Radioallergosorbent Tests 24 7/2/2024 dr bisrat

25. Diagnosis of asthma – History More than one type of symptom (wheeze, shortness of breath, cough, chest tightness) Symptoms often worse at night or in the early morning Symptoms vary over time and in intensity and triggered by infection ,exercise, weather change Isolated cough with no other respiratory symptoms Chronic production of sputum Shortness of breath associated with dizziness, light-headedness or peripheral tingling Chest pain Exercise-induced dyspnea with noisy inspiration (stridor) Increased probability of asthma Decreased probability of asthma 25 7/2/2024 dr bisrat

26. Primary Assessment tools Pulmonary Function Tests ↓ PEFR, FEV1 and FEV1/FVC Flow volume curve : Scalloping Reversibility After giving β2 agonist > After 15 minutes, * ≥ 12% or 200 ml ↑ in FEV1 or * > 20 % change in PEFR Assessment of Airway responsiveness ↑ reactivity to provocative stimuli 1. Methacholine : ≥20% drop in FEV1 with a dose ≤400 ug 2. Exercise/cold air ≥10% drop in FEV1 26 7/2/2024 dr bisrat

27. Pulmonary function test :- Volume time curve 27 7/2/2024 dr bisrat

28. Normal flow – volume loop PEFR PEFR Pulmonary function test :- Flow Volume loop 28 7/2/2024 dr bisrat

29. Eosinophil Counts ≥ 150 cells/ uL Exhaled Nitric Oxide FeNO: Approximate indicator of Eosinophillic inflammation Easily suppressed by ICS Untreated patients (>35-40 ppb) - Eosinophillic inflammation Treated patients (>20-25 ppb) - Poor adherence to therapy or Persistent type 2 inflammation Sputum examination Eosinophils vs Neutrophils imaging IgE , Skin Tests & Radioallergosorbent Tests Total serum IgE >1000 IU/ mL : ABPA Skin tests or RAST: Confirm Atopy Adjunctive assessment tool 29 7/2/2024 dr bisrat

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31. GINA 2024 Box 1-1 7/2/2024 dr bisrat 31

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44. SYGMA 1 study 44 7/2/2024 dr bisrat

45. SYGMA 2 study 45 7/2/2024 dr bisrat

46. Novel start study 46 7/2/2024 dr bisrat

47. PRACTICAL Trial 47 7/2/2024 dr bisrat

48. BEST Trial 48 7/2/2024 dr bisrat

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52. 52 Odds ratio Odds ratio 7/2/2024 dr bisrat

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55. Before considering any step up in treatment consider: Incorrect inhaler technique Poor adherence Persistent exposure at home/work to agents such as allergens, tobacco smoke, indoor or outdoor air pollution, or to medications such as beta-blockers or (in some patients) non-steroidal anti-inflammatory drugs (NSAIDs) Comorbidities that may contribute to respiratory symptoms and poor quality of life Incorrect diagnosis Step up & step down treatment for asthma 55 7/2/2024 dr bisrat

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62. Acute exacerbation of asthma 62 7/2/2024 dr bisrat

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75. references 7/2/2024 dr bisrat 75

76. THANK YOU 7/2/2024 dr bisrat 76