Management of asthma

By Dr Md Khairul Hassan Jessy

1. MANAGEMENT OF ASTHMA
Dr. Md. Khairul Hassan Jessy
Associate Professor
Respiratory Medicine
NIDCH, Mohakhali, Dhaka

5. The Goals of Asthma Management
Achieve and maintain control of symptoms
Prevent asthma exacerbations
Maintain pulmonary function as close to normal as
possible
Avoid adverse effects from asthma medications
Prevent asthma mortality

6. Asthma: Goals of Treatment
*
Control chronic and nocturnal symptoms
Maintain normal activity levels and exercise
Maintain near-normal pulmonary function
Prevent acute episodes of asthma
Minimize emergency department (ED)
visits and hospitalizations
Avoid adverse effects of asthma medications
**
Global Initiative for Asthma. GINA workshop report: global strategy for asthma management
and prevention. Available at: http://www.ginasthma.org. Accessed October 13, 2006.

7. Management of Asthma
Non-pharmacological
Education and
Caution
Pharmacological (including Routine asthma care)
Asthma medication and
Appliances
Emergency Asthma management
Management of concomitant disease
Asthma in special situation

8. Home management:
Step care management of asthma
3 fundamental components
Education
Caution
Medication

9. Non-pharmacological management of Asthma
Patient and family education to understand the
disease, and to foster self-confidence and fitness
Avoid smoking
Avoid “identified cause” where possible
Control of extrinsic factors which cause allergy
like pets, moulds and certain foodstuffs,
particularly in childhood
Avoid beta-blockers, aspirin and NSAIDs

10. Step Care Management
What to know about medication ?
We must know four points regarding medication of
asthma.
Step care management
Which step is appropriate for a specific
patient
Self management plan
 Rescue steroid therapy

11. Step Care Management
What is step care management?
Step care management is like a staircase.
We start treatment at the appropriate step.
Then we shall step up along the stairs if
asthma is not controlled or becomes more
severe
 And shall step down when patient’s
asthma is fully controlled for 3 months or
more.

12. Scoring System (Dhaka Criteria)
For Step Care Management

13. Which step is appropriate for a specific
patient ?
We are using a score system, developed at our
“National Asthma Centre NIDCH,
Dhaka” for determination of appropriate
step for a patient.

14. Scoring System for Step Care Management

Dhaka Criteria (Predicted Score = 7 – 0) Score
1.Do you have dyspnoea everyday? Yes-1, No- 0
2.Do you have nocturnal attack of dyspnoea more than
two times per month?
Yes-1, No- 0
3.Have you suffered from dyspnoeic attacks which were
severe enough to necessitate - Steroid tablets, Nebulizer
therapy, Aminophylline injection or Hospital admission?
Yes-1, No- 0
4.Do you have persistent dyspnoea for last six months or
more OR are you taking steroid tablets (Betnelan/
Prednisolone/Deltasone) for one year or more?
Yes- 3, No-
0
5.Is the patients baseline (during asymptomatic stage)
PEFR <60% of predicted value?
(This question is not applicable for children)
Yes-1, No- 0

15. Scoring System for Step Care Management

Predicted Score = 7 - 0
Score Step of Management
0 1
1 2
2 3
3 4A
4 4B
5-7 5 or 6

17. Step -1
Occasional use of reliever bronchodilator
[Short acting bronchodilator (SABA)]
No Anti-inflammatory drug

18. Step -2
Step 2: Low dose Anti-inflammatory drug
Plus
Step –1
Option : aLow dose inhaled Corticosteroid
Option: bFull dose of Cromones
Option : cLeukotriene antagonists
Option : dSustained release (SR) theophylline

19. Step -3
Step 3: High dose Anti-inflammatory drug
Plus
Supplementary Leukotriene antagonists
Plus
Step –1
Option : a High dose inhaled Corticosteroid (HDICS)
Option: b Low dose Corticosteroid PLUS Long acting b2 agonist
Option : c Low dose Corticosteroid inhaler (Option b) PLUS
Full dose Cromone inhaler OR
Sustained release Theophylline OR
Leukotriene antagonist

20. Step -4 A
Step 4 A: High Dose Anti-inflammatory Drug + Regular
Use Of Protectors
High Dose Inhaled Corticosteroids
Plus
Long Acting b
2
Agonist Inhaler
Or
Sustained Release Theophylline / Leukotriene Antagonist
Plus
Supplementary Leukotriene Antagonists &/Or Anticholinergics
Plus
Step - 1

21. Step -4 B
Step 4 B: High dose Anti-inflammatory drug + regular use
of Protectors
High Dose Inhaled Corticosteroids
Plus
Long acting b
2
agonist inhaler
Plus
Sustained release Theophylline ± Leukotriene antagonist
Plus
Supplementary Leukotriene antagonists &/or anticholinergics
Plus
Step - I

22. Step -5
Step 5: High dose Inhaled corticosteroid +
Long acting Beta agonist +
Theophylline ±
Leukotriene antagonist
And
Omalizumab for patients with allergy
Plus
Step - 1

23. Step -6
Step 6: Addition of Oral Steroid
Oral Steroid (Prednisolone)- Single Morning dose (5-20mg)

Plus
All medications of Step IV (Full dose Inhaled
corticosteroid +Long acting Beta agonist +Theophylline
± Leukotriene antagonist)
And
Consider Omalizumab for patients with allergy
Plus
Step - 1

24. Gina 2017 Update

25. Short acting oral b
2
agonist

26. Oral plain
Aminophyllin/Theophyllin
Ketotifen may be added if patient has
associated rhinitis

27. Step - 2
PLUS
Long acting oral
Salbutamol 2-8 mg 2 times daily/Bambuterol 10-20
mg at night

28. Oral Steroid (Prednisolone) Single
Morning dose
PLUS
All medications of Step 3

29. Economic Schedule
Which medication should be preferred for a patient
able to buy only one inhaler a reliever or a
preventer ?
A “Preventer Corticosteroid Inhaler” is the drug of
choice in such case. Because continuous anti-
inflammatory action of this medicine may lead to
remission of asthma.

30. If patient gives history of smoking >10 pack year
Ipratropium Bromide/Tiotropium
should be added in all Steps
from Step-2 to Step-5

31. When to step down?
Once control is achieved and sustained for 3
months a reduction of drug therapy, i.e, Step down
is indicated.
It should be slow and gradual.

32. How to step down?
At every 3 months interval
reduce the dose of inhaled corticosteroid by
25% from total dose up to minimum low dose.
Then withdraw protector drugs (Salmeterol/
Theophyllin-SR)

33. When to step up?
If not adequately controlled even after 1
months intensive medications, check for any
pitfalls & correct it, if present.
If control yet not achieved, an increase in
medications, i.e., step up is indicated.

34. How to step up?
Give medicines of the immediate higher
step.
Just add the new drug and/or increase the
dose of the existing drug.
No graduation of dosage is required.

35. Follow Up of The Patient
When to follow-up the patient?
At monthly interval till control is
achieved.
At every three months interval after
control is achieved.

36. Rescue Steroid therapy
During step care management, patient may suddenly
lose asthma control at any step.
To gain control over exacerbation again, short
courses of oral rescue steroid therapy is prescribed.
No stepping up is required prior to it. Patients should
follow the existing step after ending the rescue
course.

37. Rescue Steroid therapy
Prednisolone (30-60 mg /day) for adult or 1-2 mg /kg
/day for children in single morning dose or 2 divided
doses for 7-14 days
Or
The dose should be continued until 2 days after control is
reestablished.
Tapering of this dose to withdraw treatment is not
necessary unless given for >3 weeks.

38. Rescue Steroid therapy
Indications of Rescue steroid therapy:
Symptoms and PEF progressively worsening day by day
Fall of PEF below 60% of the patient’s personal best
recording
Persistence of morning symptoms until midday
Onset or worsening of sleep disturbance by asthma
Progressively diminishing response to an inhaled
bronchodilator
Symptoms severe enough to require treatment with
nebulised or injected bronchodilator

39. Remission and Cure
“Cure” is possible
 but still it is difficult to predict who will go
into that complete remission or cure and who
will not
If remission persists throughout life, then we can
say that patient is “cured”

40. Remission and Cure
Remission is a state in which a patient remains
asymptomatic without any drug for at least one year or
more.
‘Cure’ is difficult to apply. Asthma can be controlled.
60-80% cases of childhood asthma & 20-30% cases of
adult asthma may go into complete remission.