GINA Protocol 09

7/30/2019 GINA Protocol 09..

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BRONCHIAL ASTHMA


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Definition

Burden of Asthma

Risk Factors Mechanisms

Diagnosis and Classification

Education and Delivery of Care


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A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation leads to an increase inairway hyperresponsiveness with recurrentepisodes of wheezing, coughing, and

shortness of breath Widespread, variable, and often reversible

airflow limitation


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Risk Factors(for development of asthma)

INFLAMMATION

Airway

HyperresponsivenessAirflow Obstruction

Risk Factors

(for exacerbations)

Symptoms


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Host factors: predispose individuals to, or

protect them from, developing asthma

Environmental factors: influence susceptibilityto development of asthma in predisposed

individuals, precipitate asthma exacerbations,

and/or cause symptoms to persist


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Host Factors

Genetic predisposition

Atopy

Airway hyper-responsiveness

Gender

Race/Ethnicity

Environmental FactorsIndoor allergens

Outdoor allergens

Occupational sensitizersTobacco smoke

Air Pollution

Respiratory Infections

Parasitic infections Socioeconomic factors

Family size

Diet and drugs

Obesity


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Allergens

Air Pollutants

Respiratory infections

Exercise and hyperventilation

Weather changes

Sulfur dioxide

Food, additives, drugs


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Consider asthma if any of the ff signs and symptoms arepresent:

frequent episodes of wheezing more than once a

month

activity induced cough or wheeze

cough particularly at night during periods withoutviral infection

absence of seasonal variation in wheeze


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Symptoms occur or worsen in the presence of:

1. Aeroallergens

2. Animal furs and chemicals

3. Exercise

4. Pollen5. Changes in temperature

6. Respiratory viral infections

7. Strong emotional expression

8. Tobacco


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The patient also has eczema, hay fever or a family

history of asthma or atopic disease

Symptoms that persist after age 3

Childs colds take more than 10 days to clear up

Symptoms improve when asthma medications are given


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Controlled

Partly controlled

Uncontrolled


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Characteristic Controlled Partly controlled uncontrolled

Daytime symptoms(wheezing, cough,

difficulty ofbreathing)

None(can have attacks

less thantwice/week)

More than twice/week (short periods

or minutes)

More than twice/week (minutes-

hours and partiallyor fully relievedwith rapid actingbronchodilators)

Limitation ofactivities

None(plays and runs)

Any(may cough,

wheeze or havedifficulty ofbreathing duringexercise)

Any(may cough,

wheeze or havedifficulty ofbreathing duringexercise)

Nocturnal

symptoms orawakening

None

(no nocturnalcoughing duringsleep)

Any

(coughs or wakesup during sleep)

Any

(coughs or wakesup during sleep)

Need for reliever orrescue treatment

2 days/ week > 2 days/ week > 2 days/ week


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Lung function measurements- provide an assessment of the severity,

reversibility, and variability if airflowlimitation

Spirometry- preferred method of measuringairflow limitation and its reversibility

Peak Expiratory Flow


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An increase in FEV of 12% and 200ml afteran administration of bronchodilator indicates

reversible airflow limitation consistent withasthma

Repeated testing is advised


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Measurements are ideally compared to thepatients own best measurement using his

own peak flow meter

An improvement in 60L/min (or 20% of pre-bronchodilator PEF) after inhalation of abronchodilator or diurnal variation in PEF ofmore than 20%


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Partnership between patients family andcaretaker

Avoidance of risk factor

Assess, treat and monitor asthma control

Recognize an asthma attack


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Controlled Partly controlled uncontrolled

On as needed rapid

acting 2-agonist

On as needed rapid

acting 2-agonist

Low dose inhaledglucocorticosteroid

Continue as needed

rapid-acting 2-agonist

Low dose inhaledglucocorticosteroid

Double Low doseinhaledglucocorticosteroid

Leukotriene modifier Low dose inhaledglucocorticosteroidplus

Leukotriene modifier


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Drugs Low daily dose (ug)

Beclamethasone dipropionate 100

Budesonide MDI + spacerBudesonide nebulized

200500

Fluticasone propionate 100


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Symptoms Mild severe

Altered consciousness no Agitated, confused ordrowsy

Oximetry onpresentation

94% < 90%

Talks in sentences words

Pulse rate < 100 bpm 200bpm (0-3yrs old)

180 bpm (4-5 yrsold)

Central cyanosis absent Likely to be present

Wheeze intensity variable May be quiet


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Parameters Mild Moderate Severe

Breathless Walking, can liedown

Talking, difficultyfeeding, preferssitting

At rest stopsfeeding, hunchedforward

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated

RR Increased Increased Often >30/m

Accessory

muscles andretractions

Usually not Usually Usually


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Parameters Mild Moderate Severe

Wheezes Moderate andoften onlyexpiratory

Loud Loud

Pulse/min 120Pulsus paradoxus Absent;

25mmHg

PEF after initialbronchodilator

% predicted orpersonal best

Over 80% Approximately60-80%

60mmHg 95% 91-95% < 90%


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Indication for immediate referral to hospital

Any of the ff:

No response to 3 administrations of an inhaled shortacting 2-agonist within 1 to 2 hoursTachypnea despite 3 administrations ofan

inhaled short acting 2-agonist

Child is unable to speak or drink or breathless

Cyanosis

Subcostal retractions

92 % O2 saturation at room air

Social environment that impairs delivery of acute

treatment


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Therapy Dose and administration

Supplemental O2 4lpm

Short acting 2-agonist 2 puffs salbutamol by spacer or 2.5mg salbutamol by neb every 20 minfor 1st hr

Ipratropium 2 puffs every 20 min for the first houronly

Systemic glucocorticosteroids Oral prednisolone(1-2 mg/kg x 5days)IV methylprednisolone (1-2mg/kg )

Aminophylline Consider in ICU: LD:6-10mg/kg;

MD 1mg/kg

Oral 2 agonist no

Long acting 2-agonist no


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Thank You...

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GINA Protocol 09