1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies...

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1 1 BRONCHIAL ASTHMA BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

Transcript of 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies...

Page 1: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

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BRONCHIAL ASTHMABRONCHIAL ASTHMA

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Page 2: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

ObjectivesTo describe how to make the diagnosis of

asthma utilizing the Saudi Asthma Guidelines.To discuss the efficacy of nebulizers versus

metered dose inhalers and other medications in the treatment of asthma

To describe the following methods for monitoring disease severity and any evidence supporting one method over the otherSymptoms based (i.e. medication frequency and dose

based upon symptoms)Daily peak flow meter monitoring (i.e. red,

yellow, green zones)

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Page 3: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

DEFINITION OF ASTHMA

• CHRONIC INFLAMATORY DISORDER OF THE AIRWAY ASSOCIATED WITH WIDESPREAD BUT

VARIABLE AIRFLOW LIMITATION (PARTLY REVERSIBLE WITH OR WITHOUT TREATMENT )

• AND WITH INCREASED AIRWAY HYPERRESPONSIVENESS TO VARIETY OF

STIMULI

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WHAT IS THE PREVALENCE IN SAUDI ARABIA ?

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The prevalence of asthma among school children in KSA

• Range

4%-23% • Riyadh 10%• Jeddah 12%

( AL Frayh, et al, 2001 )

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history

• Required a full detailed medical history and clinical exam. Including peak expiratory flow (PEF)rate.

• 1-Symptoms:– Cough– Wheezing– Shortness of breath

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• How frequent, how severe, what intervention needed.

• Interfere with sport or normal physical activity• Trouble some cough between attacks• Symptoms improve by asthma medication

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• 2- atopy :skin eczema ,itchy eye,frequent nasal blockage,discharge or sneezing especialy in the morning

• 3- family history of atopic diseases.• 4- environmental history• 5- exclusion of other medical conditions

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Physical examination• Hight and weight(growth in childern)• Nose,throat, sinusis(polyps,deviated nasal

septum,post nasal drip,pale-pink or congested nasal turbinate.

• Feature of atopy• Examination of the respiratory system

– May be normal between attacks– wheeze brochi,tachypnea,chest deformity suggest

asthma– Stridor,clubbing,heart murmers ----other than

bronchial astha

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• Peak expiratory flow rate (PEF):• Should be performed in every patient>5 yrs• In certain patient measuring PEF prior to and

after a bronchodilator may help in confirming the diagnosis.

• Measuring PEF variability comparing the morning and evening PEF over a period of 2 weeks

Page 12: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

• Variability over 15% conferms but not essential for diagnosis

• PEF may be normal between attacks

Page 13: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Investigation

• Usually not necessary• CXR Usually not necessary except in

• Severe cases• Foreign body • Infection

• Arterial blood gases in severe cases

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Differential diagnosis

In children < 5 yrs :• Upper airway allergies,rhinitis, sinusitis• GERD• Foreign body aspiration• Recurrent viral LRTI• Cystic fibrosis• Congenital heart disease

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Differential diagnosisIn older children and adults:

• Upper airway allergies, rhinitis, sinusitis• GERD• Heart disease • COPD• Vocal cord dysfunction• Inhalation of foreign body• Hyperventilation and panic attack• Cough secondary to drugs(β-blockers and ACE inhibtors)• Bronchiachtiasis• Laryngeal dysfunction

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classification

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classification

• Etiology:– Allergic and non allergic asthma– Help in determining prognosis and in determining

allergen to be avoided • Severity:

– Intermittent, mild persistent, moderate persistent, severe persistent.

– Management at the initial assessment of a patient• Control:

– Useful for ongoing therapy

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Classification: asthma Severity:

classification intermittent Mildpersistent

Moderatepersistent

Severe persistent

Minor symptoms

<1/week 1-3/week 4-5/week continuous

Exacerbations/nocturnal

<1/month 1/month 2-3/month >4/month

PEF between attacks

>80% >80% 60-80% <60%

Pharmacological therapy

step1 step2 step3 step4

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Classification: asthma controlcharachtarstic controlled(all the

following)Partly controlled(any in any week)

uncontrolled

Day time symptoms None(twice or less/week)

More than twice/week

Three or more Feature of partly controlled asthma present in any weekLimitation of

activityNone Any

Nocturnal symptoms /awaking

None Any

Need for reliever /rescue treatment

None (twice or less/week)

More than twice/week

Lung function (PEF or FEV1)

Normal <80 % predicted or Personal best

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Management

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Goals of successful management

• Achieve and maintain control of symptoms• Maintain normal activity level ,including

exercise• Maintain (near) "normal" pulmonary

function. • Prevent recurrent exacerbations of asthma• Avoid adverse effects from asthma medication• Prevent asthma medication

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Component of asthma therapy

1) Develop patient /doctor partenership asthma education

2) Identify and reduce exposure to risk factors3) Assess treat and monitor asthma4) Manage asthma exacerbation emergencies5) Special consideration coexisting and related

condition

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Component 1:Develop patient /doctor partnership asthma education

• Asthma education• Asthma follow up and referal

Page 24: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 1:Develop patient /doctor partnership asthma education

Asthma educationObjectives:1- improving knowledge of

asthma2-changing attitude and

behavior3-Improving management

skills4- improving satisfaction and

overall quality of life

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Component 1:Develop patient /doctor partnership asthma education

Elements of patient education :1- basic facts about asthma:Disease, medication and goal of therapy2- socio-cultural misconception:Asthma as infectious disease,asthma medication

are addictive,3- medicationAdvantage of inhaled over systemic medications The need for more than one inhaler

Page 26: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 1:Develop patient /doctor partnership asthma education

• 4- management skillsTechnique:• Inhalation devices,spacer, PEFAsthma self management:• Name and dose of the medication• Monitoring of asthma• Sign suggest worsening of asthma• Action in exacerbation• How and when adjust medication• How and when to seek medical attention

Page 27: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 1:Develop patient /doctor partnership asthma education

Follow upInitial phase:• Last until asthma control is

optimum• The diagnnosis is

established• Patient need to be seen at

least every 3-6 weeks during this phase

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Component 1:Develop patient /doctor partnership asthma education

• Second phase:• The asthma is well controlled• Interval history, examination ,medication • Special attention include:1-need for emergency care2-loss of time in work or school3-freq. of β2 agonist usage4-wheezing interfere with normal physical activity

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Component 1:Develop patient /doctor partnership asthma education

5-use of oral steroid6-Perform spirometry or PEF in clinic7-go over PEF chart with the patient 8- observe inhalation technique 9- step up or down anti-inflammatory therapy10-provide written instruction to certain patients Patient need to be seen every 3-6 monthsOr earlier if patient deteriorate

Page 30: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 1:Develop patient /doctor partnership asthma education

Referral Primary health care centers:Manage asthma whose

diagnosis is striaght forward and are easily controlled

If asthma is partialy controlled or uncontrolled --refer to secondary care

Page 31: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 2: Identify and reduce exposure to risk factors

• Domestic dust mites• Air pollution• Tobacco smoke• Occupational irritants• Cockroach • Animal with fur• Pollen

Page 32: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

• Respiratory (viral) infections• Chemical irritants• Strong emotional expressions• Drugs ( aspirin, beta blockers)

Page 33: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 3:Assess treat and monitor asthma

• asthma Severity• asthma control

Page 34: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Asthma control test

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step1 step2 step3 step4 step5

As needed rapid –acting β2 agonist

Low dose ICS

Low dose ICS+LABA Medium to high dose ICS +LABA

Step 4 +steriods

Leukotriene modifier

Low –dose ICS + Leukotriene modifier

Medium to high dose ICS+ Leukotriene modifier

STEP 4+anti IgE

Medium to high dose ICS

Medium to high dose ICS +LABA+ Leukotriene modifier

Addition of sustained release theophylline may be considered

Page 36: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

LEVEL OF CONTROL TREATMENT OPTION

controlled Step down therapy

Maintain therapy

Partly controlled Maintain therapy

Step up therapy

Uncontrolled Step up therapy

Look up for reasons

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Component 4:Manage asthma exacerbation emergencies

• Home management:• Frequent β2 agonist

preferaply via spacer device q 4h

• Dose of ICS to be increased 4 folds

• Action plan

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Management of severe attack

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Peak Flow Meter ZonesGreen ZoneGreen Zone (80 to 100 percent of your personal best) signals

good control. Take your usual daily long-term-control medicines, if you take any. Keep taking these medicines even when you are in the yellow or red zones.

Yellow ZoneYellow Zone (50 to 79 percent of your personal best) signals caution: your asthma is getting worse. Add quick-relief

medicines. You might need to increase other asthma medicines as directed by your doctor.

Red ZoneRed Zone (below 50 percent of your personal best) signals medical alert! Add or increase quick-relief medicines and call your doctor now.

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Page 41: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Component 5:special consideration

• Rhinitis• Sinusitis• Nasal polyps• Respiratory infection• GERD• Asprin induced asthma(AIA)• Pregnancy • surgery

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• B. This patient has mild persistent asthma, which is defined as having asthma symptoms more than two times a week but less than one time a day. These patients also have nocturnal

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Is the asthma of the patient in the previous question controlled or not? What recommendations might you give her regarding her therapy?

• A. Controlled, do not change her therapy• B. Controlled, educate regarding triggers• C. Not controlled, give a short burst of oral prednisone• D. Not controlled, add a long-acting bronchodilator such as

salmeterol• E. Not controlled, add a low-dose inhaled corticosteroid or

leukotriene antagonist

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Page 44: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

• E. This patient is not well controlled since she is using her inhaler more than twice a week and experiencing symptoms so frequently. Addition of a low-dose inhaled corticosteroid or a leukotriene antagonist are appropriate options for mild persistent asthma.

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Page 45: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

The same 23-year-old patient comes in to your office 2 months later after having a kitchen fire at home and is complaining of shortness of breath. What factor on your history and physical might make you consider admitting her to the hospital?

• A. Wheezing on lung exam• B. Pulse oximetry less than 93%• C. Respiratory rate of 30 breaths per minute• D. No response to one treatment with an albuterol nebulizer• E. PaCO2 of 25

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Page 46: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

• C. A respiratory rate of greater than 28 or pulse of greater than 110 beats per minute would both indicate a severe episode. Wheezing is an unreliable indicator of the severity of attack. A pulse oximetry measurement of 90% is the goal unless the patient is pregnant or has cardiac disease. A PaCO2 of 25 is expected in a patient who is hyperventilating. A PaCO2 that is normal or elevated may be a sign of impending respiratory failure and such patients should be monitored closely in the intensive care unit

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Page 47: 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax:

Thanks

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