CURRENT GUIDELINES ON

ASTHMA MANAGEMENT
By Dr Vesta Winasi Nzuh

Based on GINA 2022 GUIDELINES

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OUTLINE
• Case Summary
• Definition
• Pathophysiology
• Management of acute exacerbation
• Outpatient management
• Asthma-COPD overlap
• Summary

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CASE PRESENTATION
• 19 year old male referred o/a acute exacerbation of asthma
• PC: difficulty breathing- 1 day
Known asthmatic, last exacerbation 3wks ago in his usual state until a
day prior to presentation when he started to experience the difficulty
breathing. Patient had recently exhausted his Ventolin inhaler. He
presented to a peripheral hospital and was referred here.
ODQ: Fever-, palpitation+, cough 4days, productive brownish sputum
+,frequency-, urgency-, dysuria-, diarrhea-, constipation-

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• PMSH: Asthmatic diagnosed
• DH: Ventolin inhaler
• Family hx- nil
• Social hx- lives at suhum, works at a poultry farm, not married, no
children, alcohol-, smoking-, nhis-, herbal preparation.

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• O/e
• Young adult male in bed, in obvious respiratory distress evidenced by
tachypnea, use of accessory muscles, afebrile(36.7), acyanotic,
anicteric, not pale, well hydrated, no palpable lymph nodes, no pedal
edema
• Resp: rr- 32cpm, spo2- 93 % in RA, Air entry was reduced bilaterally,
rhonchi present globally
• CVS: Apex l5ICSMCL, p- 115bpm bp- 106/64mmhg, s1+s2+0
• GI: abdomen full, mwr, non-tender, no organs palpable
• CNS:Grossly intact, gcs:15/15

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• Dx: Acute exacerbation of asthma ppt Pneumonia
• Plan
• Admit , counsel patient
• To do fbc, bue&cr, sputum c/s, gene x-pert, chest x-ray
• Nebulize with salbutamol 5mg qid
• Nebulise Ipratropium bromide 500mcg qid
• Nebulise Pulmicort 0.5mg bid
• Hydrate with 1 l n/s, encourage oral fluid intake
• Monitor vitals 4 hrly
• Monitor rbs 12hrly
• IV hydrocortisone 100mg 6 hourly

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Investigations
FBC RFT
WBC - 6.59 UREA - 5.4 mmol/L 1.7 - 8.1 mmol/L
NEU# - 3.39 Creatinine not run
EOS# - 0.03 10^3/uL 0.00 - 0.5 Sodium: 140
HGB - 15.1 g/dL
(MCV) - 84.2 fL 86 - 110 Potassium - 3.6 mmol/L 3.5 - 5.0
(MCH) - 28.3 pg. 26 - 38 Chloride - 97 mmol/L 97 - 107
PLT - 310.0 10^3/uL 163 - 337

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• Gene Xpert : Patient was unable to produce sputum
• Sputum c/s: Patient was unable to produce sputum
• CXR: Heterogenous opacifications in hilar regions
Otherwise normal cxr

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Chest x-ray

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• By day 2, respiratory distress had resolved, Spo2: 100% on room
air,inspiratory crepitations and expiratory rhonchi in middle and lower
zones.
• Plan
• Stop hydrocortisone
• Start prednisolone 30mg OD
• Start symbicort 2 puffs bd
• Nebulise salbutamol 5mg 4 hourly
• Iv amoxiclav 1.2g tds
• Tab azithromycin 500mg OD

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Case summary
• Day 3
• Patient had significantly improved; no respiratory distress, SPO2:100% on
room air. AE was reduced bilaterally, rhonchi in middle and lower lung
zones.
• Patient was discharged on
• Prednisolone 30mg od x 5/7
• Symbicort 2 puffs bd
• Ct azithromycin 500mg od
• Oral amoxiclav 625mg tds
• Counselled on the need to attend asthma clinic
• Patient was lost to follow up

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Questions
• What factors placed patient at risk of an exacerbation?
• What were some pitfalls in our management?
• Was patient adequately prepared for discharge?

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Answers

1. Factors which placed patient at risk of exacerbation: patient works at poultry farm, long term
SABA, lack of use of inhaled corticosteroids
2.Pitfalls : history was incomplete; when and how was asthma diagnosed?
-when was last attack
-when was last attack that required hospital admission
-history of atopy
-family history of asthma
• We did not do spirometry to get a baseline for outpatient management.
• Diagnosis of pneumonia and start of antibiotics debatable
• Diagnosis did not include severity of exacerbation
• Documentation did not include demonstration of inhaler technique
3. Was patient adequately prepared for discharge: counselling, inhaler technique, patient was
started on ics-LABA

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INTRODUCTION
• Asthma is a chronic respiratory disease characterized by airflow
obstruction, bronchial hyperresponsiveness, and airway
inflammation.
• It is a significant public health problem, affecting over 300 million
people worldwide, with an estimated 250,000 annual deaths
attributed to the disease.

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Definition
• History of variable respiratory symptoms
• Confirmed variable expiratory airflow limitation

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Definition; symptoms
Heterogenous disease characterized by chronic airway inflammation
with
• One or more symptom of of airway obstruction, wheeze, shortness of
breath, chest tightness, cough
• Symptoms worse at night or early in the morning
• Symptoms vary based on time and intensity
• Symptoms triggered by viral infections, exercise, allergen exposure,
changes in weather, laughter and irritants

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Asthma phenotypes
• Allergic asthma:Most easily recognized asthma phenotype, often
childhood onset. Associated with eczema and rhinitis. Respond well
to ICS
• Non-allergic asthma: No history of allergy. May be neutrophilic,
eosinophilic or paucigranulocytic. Less short term response to ICS
• Adult onset asthma: Usually affects females. May require higher
doses of ics or may be refractory to ics
• Asthma with persistent airway remodeling
• Asthma with obesity

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History
• Cough
• Difficulty breathing
• Wheeze
• Chest tightness
• Co-morbidities such as allergic rhinitis, eczema
• Family history of asthma, allergic rhinitis, eczema

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History
• Asthma less likely if:
➢Isolated cough with no other respiratory symptoms
➢Chronic production of sputum
➢Shortness of breath associated with dizziness, light-headedness or
peripheral tingling
➢Chest pain
➢noisy inspiration (stridor)

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Physical Examination
• Usually normal
• Expiratory rhonchi may be absent or only on forced expiration
• Wheezing is also found in other conditions, for example:
• Respiratory infections
• COPD
• Upper airway dysfunction
• Endobronchial obstruction
• Inhaled foreign body
• Pulmonary oedema
• Silent chest may be present in acute exacerbations of asthma

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Spirometry
1. Documented expiratory airflow limitation
• REDUCED FEV1
• FEV1/FVC <0.75

FEV1: Forced expired volume in one second

FVC: Total volume exhaled forcefully after maximum inspiration
PEF: Maximum flow generated on forceful exhalation

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Obstructive pattern
• PEF decreased
• Fev decreased
• FEV1/FVC decreased

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Spirometry
2. Documented excessive variability in lung function
• Positive bronchodilator responsiveness; FEV1>12% OR 200mls 10-15mins
after 200-400mcg salbutamol
• Excessive variability in twice daily PEF over 2 weeks; 10% diurnal PEF
variability
• Positive exercise challenge test: fall in fev1> 10%
• Increase in fev1>12% baseline after 4 weeks of anti-inflammatory
treatment
• Positive bronchial challenge test; FEV 12% fall from baseline after regular
doses of methacholine
• Variation in lung function between OPD visits of >12%
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Why spirometry is important
• To prevent misdiagnosis
• Asthma diagnosis is less likely to be confirmed in patients who had no
lung function done at initial diagnosis

• Peak flow meter can be used in lower resource settings

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Other tests
• Broncoprovocation test: Methacoline, histamine or mannitol may be
introduced to airway and patient assessed for hyper-responsiveness.
This test has moderate sensitivity but limited specificity
• Allergy test: atopy may increase chances a patient has asthma but is
not specific for asthma and may exclude other asthma phenotype
• Exhaled nitric oxide: Fractional concentration of exhaled nitric oxide
may be elevated in asthma due to eosinophilia. Not specific to asthma
and may exclude other phenotypes eg neutrophilic asthma

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Investigations
• Lung function
• Oxygen saturation
• ABG: Not routinely done but should if FEV1<50% predicted, or
patients not responding to initial therapy. May show type 1 or 2
respiratory failure
• Chest x-ray: If a complication or alternative diagnosis is being
entertained
• ECG: may show p-pulmonale, RBBB,RAD

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Pathophysiology
• Airway inflammation:
• The hallmark feature of asthma is chronic inflammation of the
airways, characterized by infiltration of immune cells, such as
eosinophils, mast cells, and T lymphocytes.
• The inflammatory response is triggered by exposure to environmental
allergens, irritants, or infections.
• The release of inflammatory mediators, such as histamine,
leukotrienes, and cytokines, leads to airway edema, mucus secretion,
and bronchoconstriction.

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Pathophysiology
• Bronchospasm is a reversible narrowing of the airways that occurs in
response to various stimuli, such as allergens, exercise, or cold air.
• Bronchospasm is mediated by the contraction of smooth muscle cells
in the bronchial wall, which is triggered by the release of
inflammatory mediators and activation of cholinergic nerves.

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• Prolonged exposure to inflammation and bronchospasm can lead to
structural changes in the airways, known as airway remodeling.
• Airway remodeling is characterized by thickening of the basement
membrane, increased deposition of extracellular matrix proteins, and
hypertrophy/hyperplasia of smooth muscle cells.
• Airway remodeling is associated with irreversible airflow obstruction
and decreased responsiveness to bronchodilators.

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Differential diagnosis
• COPD: persistent airflow limitation
• CHF: cardiomegaly, pulmonary oedema
• Bronchiectasis: large volumes of purulent sputum,honeycomb
appearance on cxr
• Foreign body: inspiratory stridor, reduced air entry on one side
• Pulmonary embolism: DVT, history of immobilization
• TB: onset at all ages, lung infiltrate on cxr, high local prevalence of tb

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Management of asthma
• Acute exacerbations
• Long term care

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Acute exacerbation
• Progressive increase in symptoms and decrease in lung function
usually in response to
• Poor adherence to ics + improper use of inhaler
• Viral respiratory infections
• Allergens
• Food allergy

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Assessment
• Timing of onset and cause
• Severity of symptoms
• Symptoms of anaphylaxis
• Risk factors for asthma related death
• Current reliever and controller medications

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Physical examination
• Assess for signs of severity; level of consciousness, temp, pulse,
respiratory rate, blood pressure, use of accessory muscles, ability to
complete sentences, spo2
• Complicating factors eg anaphylaxis, pneumonia, pneumothorax
• Signs of alternative diagnosis

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Factors that increase risk of asthma-related
mortality
• History of near fatal asthma requiring intubation
• Hospitalization in the last year
• Food allergy
• Over-use of SABAs
• Poor adherence/ lack of use of ics
• Recently stopped using corticosteroids
• Co-morbidities

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Mild to moderate asthma exacerbation
• Talks in phrases, prefers
sitting to lying,
• Not agitated
• Respiratory rate increased
• Accessory muscles not used
• Pulse rate 100–120 bpm
• O2 saturation (on air) 90–95%
• PEF >50% predicted or best

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Severe/Deterioration
• Unable to complete sentences
• Agitated
• Use of accessory muscles
• Respiratory rate 30/min
• Pulse rate > 120beats/min
• O2 saturation (on air) <90%
• PEF ≤50% predicted or best

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Life threatening asthma
• Feeble respiratory effort
• cyanosis
• Drowiness
• Confusion
• Silent chest

• Near fatal asthma: raised PaCO2 and/or requiring mechanical

ventilation

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Treating exacerbations
The main initial therapies include
• Repetitive administration of short-acting inhaled bronchodilators
(salbutamol)
• Early introduction of systemic corticosteroids
• Controlled flow oxygen supplementation
• Antibiotics (not recommended)

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Management ; mild to moderate
-4-10 puffs of SABA every 20mins for 1 hour, then 4-10 puffs every 3-4
hours up to 6-10 puffs every 1-2 hours
-Oral Prednisolone 40-50mg daily for 5-7 days
-Consider ipratropium bromide
-controlled oxygen targeting SpO2:93-95% (not to exceed 96%)
-antibiotics are not recommended

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Management of severe exacerbations
• Oxygen supplementation via nasal cannula or mask (target 93-95%);
outcomes are better with this target than 100% spo2
• Inhaled SABA
• Consider SAMA eg Ipratropium bromide
• SABA + SAMA =Better outcomes than SABA alone
• High dose ICS should be given within 1 hour of admission
• Systemic corticosteroids should be initiated within 1 hour of
hospitalization ;oral preferred because it is quicker, less expensive,
however iv can be used in patients too dyspneic to swallow.
Prednisolone 50mg od for 5-7 days

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• Magnesium sulphate : not routinely used but may improve outcomes
in
-FEV1<25-30%
-Patient who fail to respond to initial treatment
• High dose ics

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Not recommended
• Antibiotics
• Sedatives
• Aminophylline,theophylline

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Life threatening asthma
• Patient with life threatening asthma or deteriorating despite care
given should be assessed for ICU care

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Assessing asthma patient for discharge
Patient may be discharged if
• Symptoms improve
• PEF increase by >60%
• Oxygen saturation >94% on room air
• Resources at home adequate

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Discharge plan
• Low dose ICS-formoterol/saba as needed; SABA only not
recommended because long term use increases risk of morbidity and
mortality
• Inhaler technique should be reviewed before discharge
• Follow up in 2-7 days
• Patient should be advised to avoid triggers

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Out-patient management
• Goals: symptom control, reduced risk of adverse outcomes
• Symptom control:
❑Assess symptoms over the course of the past 4 weeks
• Risk assessment:
❑ FEV1 should be assessed at diagnosis and after 3-6 months
❑Risk factors such as smoking and comorbidities
❑Assess inhaler technique

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Asthma control

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Risk factor assessment

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Outpatient management

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Asthma-COPD overlap
• Patients with asthma may exhibit persistent airflow limitation
especially in long standing asthma. This may make differentiation
between COPD and asthma difficult especially with other risk factors
such as smoking
• Recognition of these overlapping features of both asthma and COPD
in some patients has led to description of the asthma-COPD overlap
syndrome

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 UPDATED
Step 3 - Spirometry 2017

Spirometric variable Asthma COPD Overlap

Normal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD
- FEV1/FVC <0.7 Indicates airflow Required for diagnosis Usual in asthma-COPD
limitation; may improve by GOLD criteria overlap (ACO)
FEV1 ≥80% predicted Compatible with asthma Compatible with GOLD Compatible with mild
(good control, or interval category A or B if post- ACO
between symptoms) BD FEV1/FVC <0.7
FEV1<80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post-BD
- increase in Usual at some time in Common in COPD and Common in ACO, and
FEV1 >12% and 200mL course of asthma; not more likely when FEV1 more likely when FEV1 is
from baseline (reversible always present is low low
airflow limitation)
Post-BD
- increase in High probability of Unusual in COPD. Compatible with
FEV1 >12% and 400mL asthma Consider ACO diagnosis of ACO
from baseline
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GINA 2017, Box 5-3 © Global Initiative for Asthma
Management
• COPD: LAMA+LABA+ICS
• Asthma-COPD overlap: Low to medium dose ICS. Should not be
treated with LAMA and or LABA without ICS

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SUMMARY
• Asthma is characterized by variable airflow obstruction
• Management should be personalized based on severity and risk
• ICS and LABA are the preferred controllers to prevent exacerbations
• There is the need to address modifiable risk factors such as smoking,
obesity, and allergen exposure in asthma management.

• Patient education and self-management skills is vital in improving

outcomes

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• Thank you

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References
• 2022 GINA guidelines on asthma management
• Davidson’s principles and practice of medicine, 23 rd Edition
• Oxford handbook of medicine
• Medscape

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