This patient presents with an acute exacerbation of asthma. She has a history of asthma and is experiencing tachypnea, shortness of breath, wheezing, and her symptoms are not relieved by her usual medications. On examination, she has tachycardia, tachypnea, use of accessory muscles, decreased breath sounds, and wheezing. Her oxygen saturation is low. Treatment should focus on aggressive use of bronchodilators and systemic corticosteroids to reverse the exacerbation. Close monitoring is needed given the severity of the presentation.

1. Dr. Mostafa Rashed, PGY-2
HMC
Dr. Abdul Mutaleb Al Qawasmeh
Senior consultant Family Medicine

2.  A 37 y/o female with a history of asthma, presents to the ER with
tachypnea, and acute shortness of breath with audible wheezing.
Patient has taken her prescribed medications of Cromolyn Sodium
and Ventolin at home with no relief of symptoms prior to coming to
the ER. A physical exam revealed the following: HR 110, RR 40 with
signs of accessory muscle use. Ausculation revealed decreased breath
sounds with inspiratory and expiratory wheezing and pt was
coughing up small amounts of white sputum. SaO2 was 93% on room
air. An arterial blood gas (ABG) was ordered with the following
results: pH 7.5, PaCO2 27, PaO2 75.
 HOW WOULD YOU APPROACH THIS PATIENT ?

3. A 22-year-old male presents to your office for
assessment of a chronic cough. He has just moved
to your city and will be attending the university there.
He has moved into an apartment in the basement of
a house. As soon as he moved in, he began to notice
a chronic, nonproductive cough associated with
shortness of breath. He has never had these
symptoms before, and he has no known allergies.
When he leaves for school for the day, the symptoms
disappear. The symptoms are definitely worse at night.
His landlady has three cats. He did not think he
was allergic to cats, but now he thinks that might bethe
problem.

4. On examination, his respiratory rate is 16
breaths/minutes and regular. He is in no distress
atthe present time. There are a few expiratory
rhonchiheard in all lobes. His blood pressure is
120/70mmHg, and his pulse is 72
beats/minute and regular

5. Levels of Asthma
Control
Characteristic
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 rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1) Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week

6. Goals of Long-term Management
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Prevent asthma mortality

7. 1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and PreventionAsthma Management and Prevention
Program: Five ComponentsProgram: Five Components

8. Asthma Management and
Prevention Program
 Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
 Early intervention to stop exposure to the
risk factors that sensitized the airway
may help improve the control of asthma
and reduce medication needs.
.

9. Asthma Management and
Prevention Program
 Although there is no cure for asthma,
appropriate management that includes
a partnership between the physician
and the patient/family most often
results in the achievement of control

10.  Clear communication between health care
professionals and asthma patients is key to
enhancing compliance
Component 1: Develop
Patient/Doctor Partnership

11. Component 1: Develop
Patient/Doctor Partnership
 Educate continually
 Include the family
 Provide information about asthma
 Provide training on self-management skills
 Emphasize a partnership among health
care providers, the patient, and the patient’s
family

12. Component 1: Develop
Patient/Doctor Partnership
Key factors to facilitate communication:
 Friendly demeanor
 Interactive dialogue
 Encouragement and praise
 Provide appropriate information
 Feedback and review

13. Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and
you may need to step up your treatment.
HOW TO INCREASE TREATMENT
STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.
Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL
If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical
help.

14. Factors Involved in Non-Adherence
Medication Usage
 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
 Distance to pharmacies
Non-Medication Factors
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication

15. Component 2: Identify and Reduce
Exposure to Risk Factors
 Measures to prevent the development of asthma,
and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
 Asthma exacerbations may be caused by a variety
of risk factors – allergens, viral infections,
pollutants and drugs.
 Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.

16.  Reduce exposure to indoor allergens
 Avoid tobacco smoke
 Avoid vehicle emission
 Identify irritants in the workplace
 Explore role of infections on asthma
development, especially in children and
young infants
Component 2: Identify and Reduce
Exposure to Risk Factors

17. Influenza Vaccination
 Influenza vaccination should be
provided to patients with asthma
yearly.

18. Component 3: Assess, Treat
and Monitor Asthma
 Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control

19.  A stepwise approach to pharmacological
therapy is recommended
 The aim is to accomplish the goals of
therapy with the least possible medication
Component 3: Assess, Treat
and Monitor Asthma

20. The choice of treatment should be guided by:
 Level of asthma control
 Current treatment
Component 3: Assess, Treat
and Monitor Asthma

21. Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Cromones
 Anti-IgE

22. Reliever Medications
 Rapid-acting inhaled β2-agonists
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

23. controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCEINCREASE

26. Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)

28. Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence
A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids

30. Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)

31. Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)

33. Step 4 – Reliever medication plus two or more
controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma

34. Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)

36. Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)

37.  When control has been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient

38. Levels of Asthma
Control in adults
Characteristic
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 rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1) Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week

39. Stepping down treatment when asthma is controlled
 When controlled on medium- to high-
dose inhaled glucocorticosteroids: 50%
dose reduction at 3 month intervals
(Evidence B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)

40. Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
 If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)

41. Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or long-
acting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy

42. Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended (Evidence A)

43.  Severe bronchospasm that does not respond to
aggressive therapies within 30-60 minutes
 Severe asthmatic attack with one or more of the
following:
 Dyspnea (precluding speech), accessory muscle use,
RR 35/min
 Hr > 140/min
 Peak expiratory flow < 100 l/min
 I do not measure Peak flows
 Hypercapnea ( >= 50 mmHg)

44.  Respiratory arrest or respiratory failure (PCO2
> 50 mmHg)

45.  Who do we worry about?
 Previously intubated
 Noncompliant or poorly controlled
 Psychosocial or emotional problems
 Frequent flyers
 Environmental triggers

46.  Severe respiratory distress
 Accessory muscle use
 May be hypoxemic
 Tachypneic
 Tachycardic
 Diaphoretic
 Anxious
 1-2 word dyspnea

47.  Rapid assessment
 Manage the airway
 Aggressive treatment
 Respiratory therapist at bedside
 Have all the needed equipment at the bedside
 Intubation…
 Team approach
 2 IVs

48.  Albuterol neb
 Atrovent neb
 Methylprednisolone 125 mg IV
 Terbutaline
 0.25 mg SQ q20 minutes x 3 doses
 Epinephrine
 1:1000, 0.3 mg SQ or IM q20 minutes x 3 doses
 Magnesium sulfate

49.  Possible inhibition of calcium influx into
airway smooth muscle
 Inhibits cholinergic neuromuscular
transmission
 Stabilization of mast cells and T lymphocytes
 Stimulation of nitric oxide and prostacyclin

50.  Seems to increase Functional residual capacity
and lung compliance
 May decrease fatigue of respiratory muscles
 Decreases the adverse hemodynamic effects of
large negative inspiratory swings in pleural
pressure which compromise RV and LV
performance

51.  Provides CPAP
 Delivers higher pressure in inspiration than
expiration

52.  When do you intubate an asthmatic patient?
 Persistent hypercarbia
 Hemodynamic instability
 Inability to tolerate the face mask, BIPAP..
 Exhaustion
 Altered mental status….

53. THANK YOU