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Asthma
고려대학교 안암병원 이은주 2016.6.7
Definition-1 Heterogeneous dz, characterized by chronic airway
inflammation
Dx : characteristic Sx (wheeze, shortness of breath, chest tightness, cough worse at night or in the early morning triggered by infection, exercise, allergen, weather…) + variable airflow limitation (bronchodilator reversibility test, hyperresponsiveness
test..)
Definition-2 Asthma phenotypes Allergic asthma: childhood, PHx/FHx(+) of allergic dz, eosinophilic inflammation in sputum, well response to ICH Non-allergic asthma: adult, less well to ICS Late-onset asthm: women, adult, often require higher doses of ICS relatively refractory steroid Asthma with fixed airflow limitation: long-standing, d/t remodeling Asthma with obesity: prominent Sx, little eosinophilic inflammtaion
Diagnosis-1 Confirmed variable expiratory airflow limitation*Documented excessive variability in lung function AND airflow limitation(* 아래의 test 중 하나 이상에서 증명 )
The greater the variations, the more confident the DxAt least once, when FEV1 is low, confirm that FEV1/FVC is reduced (normally >0.75-0.8)
BDR(+) Increase in FEV1 >12% & 200ml (after 200-400mcg albuterol)
Excessive variability in twice-daily PEF over 2 weeks
Average daily diurnal PEF variabilitity >10%
Significant increase in lung function after 4 weeks of anti-inflammatory Tx
Increase in FEV1 >12% & 200ml from 4 weeks of Tx (PEF > 20%)
Exercise challenge test(+) Fall in FEV1 >10% & 200ml from baselineBronchial challenge test(+) Fall in FEV1 >20% (metacholine or histamine)
Fall in FEV1 >15% (hyperventilation, hypertonic saline, or mannitol)
Excessive variation in lung function between visits(less reliable)
Variation in FEV1 >12% & 200ml between visits
Diagnosis – 2 Reversibility : improvement of FEV1(or PEF) after
bronchodilator or controller (ICS..) ≥ 12% & 200mL Variability : Sx / lung function 의 improvement /
deterioration 예 > diurnal variability
Diagnosis -3 Peak expiratory flow (PEF) diurnal PEF variability = (1-2 주간의 평균 )
≥ 10% 시 Dx 에 도움
( 밤 PEF)- ( 아침 PEF){( 밤 PEF)+ ( 아침 PEF)} /2
Diagnosis -4 Airway responsiveness methacholine, histamine, mannitol, exercise challenge PC(or PD) 20%
(+): asthma, allergic rhinitis, cystic fibrosis, COPD
Diagnosis -5 Allergic status : strong association between asthma & allergic dz skin test, specific IgE in serum (not total)
skin-prick test : 팽진≥ 3mm & 발적 ≥ 10mm
Differential Diagnosis Vocal cord dysfunction Hyperventilation, dysfunctional breathing COPD Bronchiectasis Cardiac failure Medication related cough Parenchymal lung dz, pulmonary embolism..
ClassificationCharacteristic Controlled
(All of the following)Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms None (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities None Any
Nocturnal symptoms / awakening None Any
Need for reliever / rescue treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1) Normal
< 80% predicted or personal best (if
known)
Assessment-1(Sx control)
Asthma Control Test(ACT)
Assessment-2(Future risk)Risk factors for poor asthma outcomes Potentially modifiable independent risk factors for flare-ups (exacerbations) uncontrolled asthma Sx High SABA use ( increased mortality if > 1x 200-dose canister/month) Inadequate ICS: not prescribed ICS : poor adherence : incorrect inhaler technique Low FEV1 (<60%) Major psychological or socioeconomic problems Exposures: smoking, allergen Comorbidities : obesity, rhinosinusitis, confirmed food allergy Sputum / blood eosinophilia Pregnancy Other major independent risk factors for flare-ups (exacerbations) Ever intubated or in intensive care unit for asthma ≥ 1 severe exacerbation in last 12 months Risk factors for developing fixed airflow limitation Lack of ICS Tx Exposures: smoke; noxious chemicals; occupational exposures Low initial FEV1 ; chronic mucus hypersecretion; sputum or blood eosinophilia
Risk factors for medication side-effects Systemic : frequent OCS; long-term, high dose/potent ICS; also taking P450 inhibitors Local: high-dose / potent ICS; poor inhaler technique
Medication - Controller MedicationsController Medications
Inhaled / systemic glucocorticosteroids (ICS) Leukotriene modifiers Long-acting inhaled / oral β2-agonists (LABA) Theophylline ( sustained-release) Anti-IgE
Medication - Reliever MedicationsReliever Medications
Rapid-acting inhaled β2-agonists Inhaled anticholinergics Systemic glucocorticosteroids Theophylline (short-acting) Short-acting oral β2-agonists
Control-based asthma Mx
SxExacerbationsSide-effectsPt satisfactionLung function
DxSx control & risk factors(including lung function)Inhaler technique & adherencePt preference
Asthma medicationsNon-pharmacological strategiesTx modifiable risk factors
Stepwise approach-1Step 1 Step 2 Step 3 Step 4 Step 5
Preferred controller choice
Low dose ICS
Lose doseICS/LABA
Med/highICS/LABA
Refer for add-on Txe.g. tiotropium, omalizumab,mepolizumab
Other controller options
Consider low dose ICS
LTRALow dose theophylline
Med/high dose ICS
Low dose ICS+LTRA(or + theoph)
Add tiotropiumHigh dose ICS+LTRA(or + theoph)
Add low dose OCS
Reliever As-needed SABA As-needed SABA or low dose ICS/formoterol
Stepwise approach-2 3 개월 이상 Sx, PFT 가 안정적이면 stepdown 고려 - ICS dose 를 25-50% 정도를 3 개월 이상 간격으로 줄임
만약 6-12 개월간 증상이 없고 , risk factor 가 없다면 controller 를 중단 고려 . 하지만 ICS 의 complete cessation 은 exacerbation 이 증가한다는 보고가 많아 권하지 않음 .
Manage asthma exacerbations
Repetitive administration of rapid-acting inhaled bronchodilators
Early introduction of systemic glucocorticosteroid
Oxygen supplement
Manage asthma exacerbations-1
Manage asthma exacerbations-2
Manage asthma exacerbations-4
Oxygen : target 93-95% SABA : 4-10 puffs q 20min for 1 hr 4-10 puffs q 3-4 hrs ~ 6-10 puffs q 1-2hrs (primary care) nebulizer 일때는 초기엔 continuous 이후엔 prn 으로 (adm 시 ) Epinephrine: only anaphylaxis, angioedema Systemic steroid : prednisolone 1mg/kg(max 50mg) for 5-7 days 1 시간 이내로 투여 효과 보는데 4 시간은 걸려 oral = IV Ipratropium bromide (atrovent): addictive bronchodilation 항생제는 routine 으로 주지 말 것 !!
Manage asthma exacerbations
Magnesium : MgSO4 2g/IV (20 분간 ) single dose FEV1 25-30% at presentation pt who fail to response to initial Tx 재원 기간 줄임
Leukotriene modifiers : little data to suggest a role in acute
asthma
Sedative : avoided during exacerbation
Drug side effects β2-agonists : muscle tremor, palpitation, K 저하
Anticholinergics: dry mouth, urinary retension, glaucoma
Theophylline : N/V, headache, diuresis, palpitation, arrhythmia, seizures, death… Steroid: hoarseness, oral candidiasis, truncal obesity, bruising, osteoporosis, DM, HTN, gastric ulcer, proximal myopathy, depression, cataracts
Special consideration - Pregnancy Severity : 1/3 은 호전 , 1/3 은 악화 , 1/3 은 unchanged AE 가 중기에 흔함 . 분만 도중 AE 가 흔하지는 않지만 , hyperventilation 에 의해
bronchoconstriction 발생 가능 SABA 로 조절 가능 BA 를 많이 사용시 baby 에서 HypoG 가능 (24 시간 monitoring 요망 )
Tx: theophylline, ICS, BA, leukotriene modifier(montelukast)
Exacerbation : to avoid fetal hypoxia rapid-acting BA, O2, systemic steroid
Medications
Ventolin / Atrovent (MDI)
Foster (MDI)Seretide (Diskus, MDI) Symbicort (Turbuhaler)
Oral steroid/ theophylline
Oral long acting β2-
agonist
Leukotriene modifiers
기 타
27Ref) 세레타이드 에보할러 , 벤토린 에보할러 제품 설명서
Spacer
29※ 사용법은 보조흡입기의 종류에 따라 다를 수 있으며 , 정확한 사항은 보조흡입기 사용법을 참고해주십시오 .
환자 자신의 들여 마시는 힘에 의해 약물이 비산되어 흡입 흡입기를 입에 물고 숨을 내쉬지 않도록 교육 빠르고 세게 흡입
터부헬러 (Turbuhaler)디스커스 (DisKus)
DPI : Dry Powder Inhaler
31
숨을 끝까지 내쉰다 . 한번에 강하고 깊게 들이 마신다 .
5~10 초간 숨을 참은 후 코로 숨을 천천히 내쉰다 .
손잡이를 돌려 한번에 닫는다 .
물로 입안을 깨끗이 헹군다 .
Ref) 세레타이드 디스커스 제품 설명서
Cases
Case 1 M/ 38 CC: dyspnea, wheezing (onset: 3 일전 ) PI : 약 10 일 전부터 cough, rhinorrhea 있어 오다가 내원 3 일 전부터 dyspnea, wheezing 발생하여 내원
Never smoker
PHx : DM/HTN/TBc/Hepatitis(-/-/-/-) Allergic rhinitis(+)
PEx; whole lung wheezing(+)
Case 2 M/ 51 CC: cough (onset: 3 달 전부터 ) PI : 특이 병력 없는 never smoker 남자로 3 개월 전부터 dry cough 지속되어 내원
PHx : DM/HTN/TBc/Hepatitis(-/-/-/-)
PEx: SBS without c/w
CXR 및 PNS
Esophageal 24hr pH monitoring
PFT 및 Provocation test
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