DR.

ROHAYAH ABDULLAH
FAMILY MEDICINE SPECIALIST
POLIKLINIK KESIHATAN KOTA TINGGI
EPIDEMIOLOGY
 Asthma is a common disease with
unacceptable high morbidity and
mortality
 Prevalence is increasing worldwide
 It is commonly under diagnosed and
undertreated
 Many deaths and morbidity have been
a/w inadequate treatment, under-use of
objective measurement of severity and
inadequate supervision
PREVALENCE OF ASTHMA IN
MALAYSIA
 Primary school children: 13.8%
 Children aged 13-14 years: 9.6%
 Adult (self-reported) in NHMS:
4.1%
 Prevalence was higher in rural
(4.5%) than in Urban areas (4.0%)
 Prevalence was also higher in
those with lower educational
status (5.6%) and lower income
(4.7%)
DEFINITION
 Asthma, irrespective of severity, is a chronic
inflammatory disorder of the airways.
 In susceptible individual, this inflammation
causes recurrent episodes of wheezing,
breathlessness, chest tightness and
cough particularly at night and in the early
morning
 This episodes are usually a/w widespread but
variable airflow obstruction that is often
reversible either spontaneously or with
treatment.
HOW TO DIAGNOSE
ASTHMA?
DIAGNOSING ASTHMA
 Wheezing
 H/o any of the following:

Cough – worse particularly at night/early

morning
Recurrent difficulty in breathing
Recurrent wheeze
Recurrent chest tightness
Note: Eczema, hay fever, or a family h/o asthma or atopic
diseases is often a/w asthma
 Symptoms occur or worsen at night/early morning

– awakening the patient

DIAGNOSING ASTHMA
 Symptoms occur or worsen in the
presence of:
Exercise
Animals
Pollen
Aerosol chemicals
Dust mites (in mattress, pillows, upholastered
furniture, carpets)
Respiratory tract infection
Smoke (tobacco, wood)
Changes in temperature
Drugs (aspirin, beta blockers)
Strong emotional expression (laughing or crying
hard)
DIAGNOSING ASTHMA
 Reversible and variable airflow limitation- as
measured by a PEF meter in any the following
ways:
PEF increases > 15%, 15 to 20 min after inhaling a
short-acting beta2-agonist, or
PEF varies > 20% from morning measurement upon
arising to measurement 12 hours later in patient who
are taking a bronchodilator (> 10% in patients who
are not taking a bronchodilator), or
PEF decreases >15% after 6 minutes of running or
exercise
MANAGEMENT OF CHRONIC
ASTHMA

The aims of management are

To abolish day and night symptoms of asthma
To restore normal or best possible long term
airway function
To prevent most acute attacks
To prevent mortality
APPROACH TO
MANAGEMENT
Educating patient and family
members
Identifying and avoiding trigger
factors
Assessing severity and monitoring
response to treatment
Selecting appropriate medications
and using the lowest effective dose
to minimise short and long term
side effects
DRUG TREATMENT
3 major groups of medications:
2. Anti-inflammatory
medications
3. Long-acting bronchodilators

4. Short-acting bronchodilators
Anti-inflammatory
medications
 Reducing the inflammation will decrease
bronchial hyper-responsiveness
 3 types:
i) Corticosteroids
- the main prophylactic drugs
ii) Cromones eg. Sodium cromoglycate
- It is effective in the symptomatic and
prophylactic management of mild
persistent asthma but less effective in
more severe asthma
i) Antileukotrienes e.g Montelukast

- have some effect in controlling mild persistent

asthma
- Possible role as an alternative to low dose
inhaled
corticosteroid and as add-on therapy to
inhaled corticosteroid
- to reduce the requirement for high doses of
inhaled corticosteroids
- may also be used for aspirin sensitive asthma
and
exercise-induced asthma
EDUCATION OF PATIENT AND FAMILY
 Nature of asthma
 Preventive measure/avoidance of triggers
 Drugs used and their side-effects
 Peak flow monitoring
 Proper technique of using inhaled drugs
 Recognition of features of worsening asthma
(increase in bronchodilator requirement,
development of nocturnal symptoms,
deteriorating PEFR)
 Knowledge of the difference between relieving
and preventive medications
 Self management plan
 The danger of non-prescriibed self medication
including certain traditional medicines
PREVENTION IS BETTER

THAN CURE
ACUTE SEVERE ASTHMA
 WHY DO PAITENTS DIE:

 DISEASE FACTORS

 MEDICAL MANAGEMENT FACTORS

 PATIENTS BEHAVIOUR,PSYCHOSOCIAL
FACTORS
 DISEASE FACTORS
 CHRONIC SEVERE B.A.

 IN A MINORITY MILD OR MODERATE

 BRONCHIAL ASTHMA
 MEDICAL MANAGEMENT
FACTORS
 INADEQUATE TREATMENT
 INADEQUATE OBJECTIVE MONITORING
 INADEQUATE FOLLOW UP
 NOT REFERRING TO SPECIALIST
 NOT GIVEN WRITTEN MANAGEMENT
PLAN
 INCREASING USE OF BETA2AGONIST
 MEDICAL MANAGEMENT
FACTORS CONTD.
 INAPPROPRIATE PRESCRIPTION OF
BETABLOCKER THERAPY

 HEAVY SEDATION

 PATIENT SENSITIVE TO NSAID

 ADVERSE PSYCHOSOCIAL
&
BEHAVIOURAL FACTORS

 NON-COMPLIANCE WITH TT. OR MONITORING

 FAILURE TO ATTEND APPOINTMENTS

 SELF DISCHARGE FROM HOSPITAL

 PSYCHOSIS, DEPRESSION,OTHER PSY.ILLNESS OR SELF

HARM

 CURRENT OR RECENT MAJOR TRANQUILISER USE

 DENIAL

 ALCOHOLOR DRUG ABUSE

PSYCHOSOCIAL OR BEHAVIOURAL
FACTORS
 OBESITY

 LEARNING DIFFICULTY

 EMPLOYMENT PROBLEMS

 INCOME PROBLEMS

 SOCIAL ISOLATION

 CHILDHOOD ABUSE

 SEVERE DOMESTIC, MARITAL OR LEGAL STRESS.

OTHER RISK FACTORS FOR DEVELOPING
NEAR FATAL OR FATAL ASTHMA
 PREVIOUS NEAR FATAL ASTHMA

 PREVIOUS ADM .FOR B.A. ESPECIALLY IF IN THE LAST

YEAR

 REQUIRING THREE OR MORE CLASSES OF ASTHMA

MEDICATION

 HEAVY USE OF BETA AGONIST

 RPT. ATTENDANCES @ A&E ESPECIALLY IN THE LAST

YEAR

 BRITTLE ASTHMA
HEALTH CARE PROFFESSIONALS

MUST BE AWARE THAT PATIENTS

WITH SEVERE ASTHMA & ONE OR

MORE ADVERSE PSYCHOSOCIAL

FACTORS ARE AT RISK OF DEATH

 PREDICTION
&PREVENTION OF A
SEVERE ATTACK
 88-92% ATTACKS DEVELOP OVER 6 HRS

 80%MAY EVEN DEVELOP IT OVER 48 HRS.

 THEREFORE TIME FOR EFFECTIVE ACTION

`& POTENTIALTO REDUCE HOSPITAL
ADMISSION
A SPECIALIST SHOULD FOLLOW UP

PATIENTS ADMITTED WITH SEVERE

ASTHMA FOR AT LEAST ONE YEAR

AFTER ADMISSION
 AIMS OF MANAGMENT
 TO PREVENT DEATH
 TO RELIEVE SYMPTOMS
 TO RESTORE PATIENTS LUNG
FUNCTION
TO THE BEST POSSIBLE LEVEL AS
SOON
AS POSSIBLE.
 TO PREVENT EARLY RELAPSE
 ASSESSMENT
 NEED TO ASSESS SEVERITY RAPIDLY
 GIVE APPROPRIATE TREATMENT

 HISTORY
 PHYSICAL EXAMINATION
 PEFR MEASUREMENT
 INITIAL ASSESSMENT
 MILD ASTHMA:
 PERSISTENT COUGH
 INCREASED CHEST TIGHTNESS

 BREATHLESS WHEN WALKING

 NORMAL SPEECH

 PULSE RATE <100/MIN.

 RESP. RATE<25/ MIN

 MODERATE WHEEZE

 PEF . 75% OF PT’S BEST OR PREDICTED

 SpO2 .95% ON ROOM AIR

 MODERATE ASTHMA
 INCREASING SYMPTOMS

 PEF >50-75% BEST OR PREDICTED

 NO FEATURES OF ACUTE SEVERE

ASTHMA
 ACUTE SEVERE ASTHMA
 ANY ONE OF:
 PEF33-50% BEST OR PREDICTED

 RESP. RATE>25/MIN

 HEART RATE.> 100/MIN.

 INABILITY TO COMPLETE SENTENCES IN

ONE BREATH.
 Life threatening
asthma
 CENTRAL CYANOSIS
 FEEBLE RESPIRATORY EFFORT
 SILENT CHEST
 BRADYCARDIA
 EXHAUSTION
 CONFUSION
 PEF<30% OF BEST OR PREDICTED(<100L/MIN)
 ABG:
NORMALORHIGH PaCO2
SEVERE HYPOXAEMIA(60mmHG)
LOW pH
 REFERRAL TO
INTENSIVE CARE
 ACUTE SEVERE OR LIFE THREATENING ASTHMA
NOT RESPONDING TO
THERAPY , EVIDENCED BY:

 DETERIORATING PEF
 PERSISTENT OR WORSENING HYPOXIA
 HYPERCAPNIA
 ABG:
 EXHAUSTION FEEBLE RESPIRATION
 DROWSINESS,CONFUSION
 COMA, RESPIRATORYARREST
 ASSESMENT OF RESPONSE
TO INITIAL TT.

RESPONSE TO TT. IS MONITORED BY:

 SYMPTOMS

 PHYSICAL FINDINGS

 PEF MEASUREMENT 15-30 MIN. AFTER INITIAL TT.

 RESPONSE TO INITIAL
TT.
GOOD RESPONSE IS:
 RELIEVED OF DYSPNOEA
 IMPROVED CLINICAL STATUS
 POST TT. PEF >75% OF BEST O PREDICTED
VALUE.

INCOMPLETE RESPONSE:
 PERSISTENT SYMPTOMS & SIGNS
 PEF50-75% OF BEST OR PREDICTED VALUE
 RESPONSE TO INITIAL TT.

POOR RESPONSE:
 PERSISTENT OR DETERIORATING
SYMPTOMS & SIGNS

 PEF<50%
BEFORE DISCHARGE FROM
A&E
 REVIEW ADEQUACY OF USUAL TT.
&STEP UP IF NECCESARY
 ENSURE PT. HAS ENOUGH SUPPLY OF
MEDICATION
 CHECK INHALER TECHNIQUE
 FOLLOW UP WITHIN 2 WKS. OR EARLIER
 ADVISE PT. TO RETURN IMMEDIATELY IF
ASTHMA WORSENS
 MANAGEMENT IN THE WARD
 CONTINUE O2 >40%
 I.V HYDROCORTISONE 6 HRLY/ PREDNISOLONE
30-60MG DLY.
 NEBULISED BETA AGONIST EVERY 15MIN--2-

4HRLYDEPENDING ON SEVERITY +
ANTICHOLINERGIC.
IF STILL NO IMPROVEMENT:
 I.V. AMINOPHYLLINE>0.5-0.9MG/KG/HR. IF
CONTINUED FOR MORE THAN 24 HRS MONITOR
BLOOD LEVELS. ALTERNATIVE :
 BETA AGONIST INFUSION 3-20mcg./MIN AFTER

INITIAL I.V.BOLUS OF 250mcg.OVER 10 MIN.

 MANAGEMENT IN WARD
(CONTD.)

STILL INADEQUATE RESPONSE:

 MAY GIVE I.V. MAGNESIUM SULPHATE

2G.IN 50ML. N/SALINE INFUSED OVER
10-20 MIN.
 MONITORING RESPONSE
 PEF. MEASUREMENT 15-30 MIN LATER

 MAINTAIN ARTERIAL O2 SATURATION

ABOVE 92%

 RPT. ABG IF INITIALLY WAS NECESSARY

OR IF PT. DETERIORATES.

 MONITOR PEF AT LEAST 4 TIMES DAILY.

 OTHER
INVESTIGATIONS

 SERUM ELECTROLYTES:

 HYPOKALAEMIA IS A RECOGNISED
COMPLICATION
OF TT. WITH BETA AGONIST
&CORTICOSTEROIDS

 E.C.G. IF INDICATED
 REFERRAL TO INTENSIVE
CARE
 ACUTE SEVERE OR LIFE THREATENING ASTHMA NOT
RESPONDING TO THERAPY , EVIDENCED BY:

 DETERIORATING PEF
 PERSISTENT OR WORSENING HYPOXIA
 HYPERCAPNIA
 ABG:
 EXHAUSTION FEEBLE RESPIRATION
 DROWSINESS,CONFUSION

 COMA, RESPIRATORYARREST
 DISCHARGE PLAN FOR
HOSPITALISED PT.
BEFORE DISCHARGE PT. SHOULD BE:

 STARTED ON INHALED STEROIDS FOR AT LEAST 48 HRS +

CONTINUE ORAL STEROIDS FOR FEW DAYS MORE +
BRONCHODILATORS

 STABLE ON MEDICATIONS PT. IS GOING TO TAKE OUTSIDE

THE HOSP. FOR AT LEAST 24 HRS.

 PEF>75%, DIURNAL VARIABILITY OF <20%, ABLE TO USE

INHALER CORRECTLY, IF NECESSARY ALTERNATIVE
INHALER DEVICES COULD BE PRESCRIBED.

 DISCHARGE PLAN
(CONTD.)
PT. IS EDUCATED ON :
 DISCHARGE MEDICATION

 HOME PEF MONITORING

 SELF MANAGEMENT PLAN(FOR SELECTED, MOTIVATED PTS.)

 IMPORTANCE OF REGULAR FOLLOW UP.

 EARLY F.U : REASSESSMENT OF MEDICATION

&

MOTIVATION