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MANAGEMENT OF

ASTHMA AT PRIMARY
CARE LEVEL
Training Module For Health
Care Providers

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CONTENTS

PAGE CHAPTER I

MANAGEMENT OF ASTHMA

1 Topic 1 Management of Asthma at Primary Care level

41 Topic 2 Update on Management of Asthma and Assessment Tool

47 Topic 3 Assessment and monitoring asthma and clinical action plan

51 Topic 4 Management of Childhood asthma according to Malaysia CPG

63 Topic 5 Inhaler technique and pharmacotherapy in asthma management.

87 Topic 6 Application of Peak Flow Meter (PFM) and Spirometry in management of asthma

97 Topic 7 How to interpret Spirometry result


CHAPTER II

QUALITY ININATIATIVE OF ASTHMA


103 QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”

CHAPTER III
ASTHMA DSA PROJECTS

111 1. Management of bronchial asthma in health clinic: outcome & remedial measures conducted
at Health Clinic Tampin since 2008

117 2. Improving QA asthma through a district specific approach - District Office Kuala Langat

123 3. Elevate the percentage of controlled bronchial asthma at Pendang District

133 4. Increase the implementation of Controlled Asthma among the asthmatic patient in Perlis

139 Appendix I

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CONTRIBUTORS

Dr Kamaliah binti Mohamad Noh Dr Noraini binti Yusoof


Deputy Director Public Health Physician
Primary Care Sector Primary Care Sector
Family Health Development Division Family Health Development Division

Dato’ Dr Hj Abdul Razak Muttalif Dr Iskandar Firzada bin Hj Osman


Respiratory Consultant Family Medicine Specialist
Institute of Respiratory Medicine Health Clinic Jaya Gading,
Hospital Kuala Lumpur Kuantan, Pahang

Dr Norzila binti Mohamed Zainudin Dr Norsiah binti Ali


Consultant Family Medicine Specialist
Paediatric Institute Health Clinic Tampin,
Hospital Kuala Lumpur Negeri Sembilan

Dr Norhayati binti Mohd Marzuki Dr Nor Azila binti Mohd Isa


Specialist Family Medicine Specialist
Institute of Respiratory Medicine Health Clinic Telok Datuk,
Hospital Kuala Lumpur Banting, Selangor

Dr Fatanah binti Ismail Dr Junaidah binti Ishak


Public Health Physician Public Health Physician
Primary Care Sector Primer Officer, Perlis
Family Health Development Division
Pn Syuhadah binti Ahad
Dr Nazma binti Salleh Pharmacist
Public Health Physician Hospital Melaka
Primary Care Sector
Family Health Development Division Ruzita Bt Saad
Nurse
Health Clinic Pendang,
Kedah.

EDITORS

1. Dr Fatanah binti Ismail 3. Dr Natasya Nur binti Mohd Nasir


Public Health Physician Medical Officer
Primary Care Sector Primary Care Sector
Family Health Development Division Family Health Development Division

2. Dr Nazma binti Salleh


Public Health Physician
Primary Care Sector
Family Health Development Division

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INTRODUCTION

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by


the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that
vary over time and in intensity, together with variable expiratory airflow limitation. Symptoms are triggered
by viral infections (colds), exercise and allergen exposure, changes in weather, laughter, or irritants such as
car exhaust fumes, smoke or strong smell trigger.

The narrowing of the airways and increase in mucus production due to these trigger factors, will reduces
the flow of air in and out of the lungs, resulting in an asthma attack. It is estimated that there are 300
million asthmatics globally. National Health Morbidity Survey 2006 showed a prevalence of adult asthma
was 4.5% and childhood asthma up till 18 years old was 7.14%. Intermittent asthma among adult was 7.2%
and persistent asthma has 25.8% while 68.1 % experience acute exacerbations of bronchial asthma.

Level of asthma control among community is still low at 32.9% in a study done in Perak from 2007 till
2009. In a 2009 study done in Selangor, 93.8% of asthmatic patients did not perform the PEF test, 62.7%
demonstrated a wrong inhaler technique and only 66.3 % patient knew the care plan for an acute asthma
attack Therefore, there is an urgent need for the management and monitoring of asthmatic patient at the
primary care level to be strengthened.

Patient’s knowledge to manage their asthma is highly dependent on patient education given to them by
the healthcare provider. In the primary care clinic the patient is handled by the primary health care team
including doctors, nurses, assistant medical officer, pharmacist and assistant pharmacist. In service training
of the primary health care team to maintain competency in managing asthma need to be conducted regularly
at the implementation level. With the development of this module the training for providers at primary care
setting will be facilitated.

During the workshop and the course, all the physicians such as Respiratory Physicians, Family Medicine
Specialist, Public Health Specialist, Pharmacist, and the paramedic shared their experiences and made
initiatives in developing this module. Good practices, innovation and learning tools in implementation of
asthma are shared in this module

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TOPIC 1

MANAGEMENT
OF ASTHMA
AT PRIMARY
CARE LEVEL

Training Module For


Health Care Providers

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TOPIC 1: MANAGEMENT OF ASTHMA AT PRIMARY
CARE LEVEL TRAINING MODULE FOR HEALTH
CARE PROVIDERS

Learning objective
• Definition and pathophysiology of asthma will be discussed in this chapter
• The paramedic will be able to use clinical examination, investigation and assessment tools during
triaging at the health clinic.

MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

SLIDE 1 Outline
1. Definition
2. Pathophysiology
3. Outcome
4. Diagnosis
5. Classification
6. Management

SLIDE 2 Definition
Chronic lung heterogeneous disease characterised by recurrent/episodic/paroxysmal
breathing problems & symptoms such as;
• Breathlessness
• Wheezing
• Chest tightness
• Coughing

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SLIDE 3 Symptoms of asthma attack


SLIDE 4 Definition


Normal Lungs Asthma Lung

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SLIDE 5 Pathophysiology
• Chronic inflammatory disorder of the airways. (Host)
• Airways are hyperresponsive; become obstructed (bronchoconstriction, mucus
plugs, & increased inflammation) when exposed to various risk factors. (Host)
• Common risk factors; allergens (house dust mites, animals with fur, cockroaches,
pollens, molds), occupational irritants, tobacco smoke, respiratory (viral)
infections, exercise, strong emotional expressions, chemical irritants, &
drugs (aspirin & beta blockers). (Environment)

SLIDE 6 Pathophysiology

Airway lumen
Ciliated
epithelial cells

Blood vessel

Constricted
Bronchioles
Bronchial
smooth muscle Mucous gland

SLIDE 7 Outcome
• Acute respiratory failure.
• Irreversible airflow limitation (airways remodelling).
• Troublesome symptoms night & day.
• Limitations of physical activities / activities of daily living.

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SLIDE 8 Diagnosis
Several ways:
• Clinical symptoms & medical history.
• Lung function measurement.
• Trial of treatment; marked clinical improvement during the treatment &
deterioration when treatment is stopped.

Clinical symptoms & medical history;


• Recurrent cough / wheeze / difficult breathing / chest tightness particularly
at night or in the early morning or after exposure to risk factors or worsen at
night (awaken the patient) & has eczema, hay fever, family history of asthma or
atopic diseases.
• Patients colds “go to the chest” or take more than 10 days to clear up.

Clinical symptoms & medical history (<5 years);


• Frequent episodes of wheezing – more than once a month.
• Activity-induced cough or wheeze.
• Cough particularly at night during periods without viral infections.
• Symptoms that persist after age 3 years.
• Symptoms occur or worsen in the presence of risk factors.
• The child’s colds repeatedly “go to the chest” or take more than 10 days to
clear up.
• Symptoms improved when asthma medication is given.

Physical examination in people with asthma;


• Often normal
• The most frequent finding is wheezing on auscultation, especially on forced
expiration.

Wheezing is also found in other conditions, for example;


• Respiratory infections.
• COPD.
• Upper airway dysfunction.
• Endobronchial obstruction.
• Inhaled foreign body.

Wheezing may be absent during severe asthma exacerbations (‘silent chest’).

Lung function test / measurement;


1. Provide an assessment of the severity, reversibility, & variability of the airflow
limitation (confirm diagnosis).
2. Spirometry; ↑ FEV1 > 12% & > 200 ml after bronchodilator (reversibility).
3. Peak Expiratory Flow (PEF);
Compared to previous best measurements using his/her own peak flow meter.
§
↑ 60 L/min (> 20%) after bronchodilator (reversibility) or diurnal variation >
§
20% (2x daily, > 10%) (Variability).

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SLIDE 9 Diagnosis

SLIDE 10

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SLIDE 11

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SLIDE 12

SLIDE 13 Diagnosis
Diagnostic Challenges
• Cough-variant asthma
• Exercise-induced bronchoconstriction
• Children 5 years & younger
• Asthma in the elderly
• Occupational asthma
• Asthma-COPD Overlap Syndrome (ACOS)

SLIDE 14 Classification
1. Classification of asthma severity by clinical features before treatment.
2. Assessment of levels of asthma control;
• Clinical symptoms & objective measurement;
- GINA Guidelines
• Clinical symptoms & subjective perception;
- Asthma Control Test (ACT)

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SLIDE 15 Classification of asthma severity by clinical features before treatment

SYMPTOMS

  - Symptoms is daily
  - Frequent exacerbations
Severe - Frequent nocturnal asthma symptoms
Persistent - Limitations of physical activity
- FEV1 or PEF ≤ 60% predicted
- PEF or FEV1 Variability > 30 % 

  - Symptoms daily
  - Exacerbations may affect activity and sleep
  - Nocturnal symptoms more than once a week
Moderate - Daily use of inhaled short acting β2 - agonist
Persistent - FEV1 or PEF 60% - 80% predicted
- PEF or FEV1 Variability > 30%

  - Symptoms more than once a week but less than once a day
Mild - Exacerbations may affect activity and sleep
Persistent - Nocturnal symptoms more than twice a month
- FEV1 or PEF ≥ 80% predicted
- PEF or FEV1 Variability < 20 – 30%

Intermittent - Symptom less than once a week


- Brief exacerbations Nocturnal symptoms not more than
twice a month FEV1 or PEF ≥ 80% predicted
- PEF or FEV1 Variability < 20 %


SLIDE 16 GINA Assessment of Asthma Control
1. Asthma control – two domains
• Assess symptom control over the last 4 weeks.
- Assess risk factors for poor outcomes, including low lung function.
2. Treatment issues
• Check inhaler technique and adherence.
• Ask about side-effects.
• Does the patient have a written asthma action plan?
• What are the patient’s attitudes and goals for their asthma?
3. Co-morbidities
• Think of rhino sinusitis, GERD, obesity, obstructive sleep apnoea,
depression, anxiety.
• These may contribute to symptoms and poor quality of life.

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SLIDE 17 GINA Assessment of Asthma Control and assessment of asthma
control (adult and children) (appendix 1: Topic Management of
Asthma at primary care level)

SLIDE 18 Management

Treatment book for asthmatic patient

SLIDE 19 Primary prevention of asthma


1. The development and persistence of asthma are driven by gene -environment
interactions.
2. Current recommendations are;
• Avoid exposure to tobacco smoke (ETS) in pregnancy and early life.
• Encourage vaginal delivery.
• Advise breast-feeding for its general health benefits.
• Where possible, avoid use of paracetamol (acetaminophen) and broad-
spectrum antibiotics in the first year of life.

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SLIDE 20 Treating asthma to control symptoms and minimize risk
Goals of asthma management
1. The long-term goals of asthma management are;
• Symptom control: to achieve good control of symptoms and maintain
normal activity levels.
• Risk reduction: to minimize future risk of exacerbations, fixed airflow
limitation and medication side-effects.

2. Achieving these goals requires a partnership between patient and their health
care providers;
• Ask the patient about their own goals regarding their asthma.
• Good communication strategies are essential.
• Consider the health care system, medication availability, cultural and
personal preferences and health literacy.

3. Establish a patient-doctor partnership.

4. Manage asthma in a continuous cycle;


- Assess
- Adjust treatment (pharmacological and non-pharmacological)
- Review the response

5. Teach and reinforce essential skills;


- Inhaler skills
- Adherence
- Guided self-management education;
- Written asthma action plan
- Self-monitoring
- Regular medical review (follow-up)


SLIDE 21 The control based asthma management cycle

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SLIDE 22 Choosing between controller options on population level decisions

Choosing between treatment options at a population


e.g. National formularies, health maintenance organisations, national guidelines
The ‘preferred treatment’ at each step is based on:
q Efficacy Based on group mean data for symptoms,
q Effectiveness exacerbations and lung function (from RCTs,
pragmatic studies and observational data)
q Safety
q Availability and cost at the population level

SLIDE 23 Choosing between controller options – individual patient decisions

Decisions for individual patients


Use shared decision – making with the patient / parent / carer to discuss the
following:
1. Preferred treatment for symptoms control and for risk reduction
2. Patient characteristics (phenotype)
- Does the patient have any known predictors of risk or response
(e.g. smoker, history of exacerbations, blood eosinophilia)
3. Patient preference
- What are the patient’s goals and concerns for their asthma
4. Practical issues
- Inhaler technique – can the patient use the device correctly after
training?
- Adherence: how often is the patient likely to take medication?
- Cost: can the patient afford the medication

Choosing between controller options – individual patient decisions


• Inhaled medications are preferred because drugs delivered directly to the
airways, results in potent therapeutic effects with fewer systemic side effects.
• Inhaled glucocorticosteroids – most effective controller.
• Spacer makes inhalers easier to use & reduce systemic absorption & side effects
of inhaled glucocorticosteroids.

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SLIDE 23 Choosing between controller options –individual patient decisions


SLIDE 24 Initial controller treatment for adults, adolescents and children
6–11 years
1. Start controller treatment early;
– For best outcomes, initiate controller treatment as early as possible after
making the diagnosis of asthma.
2. Indications for regular low-dose ICS - any of;
– Asthma symptoms more than twice a month.
– Waking due to asthma more than once a month.
– Any asthma symptoms plus any risk factors for exacerbations.
3. Consider starting at a higher step if;
– Troublesome asthma symptoms on most days.
– Waking from asthma once or more a week, especially if any risk factors for
exacerbations.
4. If initial asthma presentation is with an exacerbation;
– Give a short course of oral steroids and start regular controller treatment
(e.g. high dose ICS or medium dose ICS/LABA, then step down).


SLIDE 25 Initial controller treatment
1. Before starting initial controller treatment;
• Record evidence for diagnosis of asthma, if possible.
• Record symptom control and risk factors, including lung function.
• Consider factors affecting choice of treatment for this patient.
• Ensure that the patient can use the inhaler correctly.
• Schedule an appointment for a follow-up visit.
2. After starting initial controller treatment;
• Review response after 2-3 months, or according to clinical urgency.
• Adjust treatment (including non-pharmacological treatments).
• Consider stepping down when asthma has been well-controlled for 3
months.

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SLIDE 26 Stepwise approach to control asthma symptoms and reduce risk

*For children 6-11 years, theophyline is not recommended, and preferred Step 3 is medium dose ICS.
** for patients prescribed BDP / Formoterol or BUD / formateral maintannce and reliever therapy.

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SLIDE 27 Stepwise management – pharmacotherapy

SLIDE 28 Stepwise management – additional components

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SLIDE 29 Step 1 – as-needed inhaled short-acting beta2-agonist (SABA)

SLIDE 30 Step 1 – as-needed reliever inhaler


1. Preferred option: as-needed inhaled short-acting beta2-agonist (SABA);
• SABAs are highly effective for relief of asthma symptoms.
• However …. There is insufficient evidence about the safety of treating
asthma with SABA alone.
• This option should be reserved for patients with infrequent symptoms
(less than twice a month) of short duration, and with no risk factors for
exacerbations.

2. Other options
• Consider adding regular low dose inhaled corticosteroid (ICS) for patients
at risk of exacerbations.

Short Acting Beta Adrenergic (SABA) Inhaled Corticosteroids (ICS)


inhaler

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SLIDE 31 Step 2 – low-dose controller + as-needed inhaled SABA

1. Preferred option: regular low dose ICS with as-needed inhaled SABA;
• Low dose ICS reduces symptoms and reduces risk of exacerbations and
asthma-related hospitalization and death.

2. Other options;
• Leukotriene receptor antagonists (LTRA) with as-needed SABA;
- Less effective than low dose ICS.
- May be used for some patients with both asthma and allergic rhinitis,
or if patient will not use ICS.

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SLIDE 32 Step 3 – one or two controllers + as-needed inhaled reliever

1. Before considering step-up;


• Check inhaler technique and adherence, confirm diagnosis.

2. Adults/adolescents: preferred options are either combination low dose ICS/


LABA maintenance with as-needed SABA,OR combination low dose ICS/
formoterol maintenance and reliever regimen*
• Adding LABA reduces symptoms and exacerbations and increases FEV1,
while allowing lower dose of ICS.

3. Children 6-11 years: preferred option is medium dose ICS with


as-needed SABA.

4. Other options;
• Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA).
• Children 6-11 years – add LABA (similar effect as increasing ICS).

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SLIDE 33 Step 4 – two or more controllers + as-needed inhaled reliever

1. Before considering step-up;


• Check inhaler technique and adherence

2. Adults or adolescents: preferred option is combination medium dose ICS/LABA


with as-needed SABA, OR combination low dose ICS/formoterol as maintenance
and reliever regimen*
• Children 6–11 years: preferred option is to refer for expert advice.
• Other options (adults or adolescents);
- Trial of high dose combination ICS/LABA, but little extra benefit and
increased risk of side-effects.
- Increase dosing frequency (for budesonide-containing inhalers).
- Add-on LTRA or low dose theophylline.

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SLIDE 34 Step 5 – higher level care and/or add-on treatment

1. Preferred option is referral for specialist investigation and consideration of


add-on treatment;
• If symptoms uncontrolled or exacerbations persist despite Step 4
treatment, check inhaler technique and adherence before referring.
• Add-on omalizumab (anti-IgE) is suggested for patients with moderate or
severe allergic asthma that is uncontrolled on Step 4 treatment.

2. Other add-on treatment options at Step 5 include;


• Sputum-guided treatment: this is available in specialized centres; reduces
exacerbations and/or corticosteroid dose.
• Add-on low dose oral corticosteroids (≤7.5mg/day prednisolone
equivalent): this may benefit some patients, but has significant systemic
side-effects. Assess and monitor for osteoporosis.

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SLIDE 35 Low, medium and high dose inhaled corticosteroids
Adults and adolescents (≥12 years)

• This is not a table of equivalence, but of estimated clinical comparability.


• Most of the clinical benefit from ICS is seen at low doses.
• High doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects.


SLIDE 36 Low, medium and high dose inhaled corticosteroids
Children 6–11 years

• This is not a table of equivalence, but of estimated clinical comparability.


• Most of the clinical benefit from ICS is seen at low doses.
• High doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects.

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SLIDE 37 Reviewing response and adjusting treatment
1. How often should asthma be reviewed?
• 1-3 months after treatment started, then every 3-12 months.
• During pregnancy, every 4-6 weeks.
• After an exacerbation, within 1 week.

2. Stepping up asthma treatment;


• Sustained step-up, for at least 2-3 months if asthma poorly controlled;
- Important: first check for common causes (symptoms not due to
asthma, incorrect inhaler technique, poor adherence).
• Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen;
- May be initiated by patient with written asthma action plan.
• Day-to-day adjustment;
- For patients prescribed low-dose ICS/formoterol maintenance and
reliever regimen*

3. Stepping down asthma treatment;


• Consider step-down after good control maintained for 3 months.
• Find each patient’s minimum effective dose that controls both symptoms
and exacerbations.

SLIDE 38 General principles for stepping down controller treatment


1. Aim
• To find the lowest dose that controls symptoms and exacerbations, and
minimizes the risk of side-effects.

2. When to consider stepping down;


• When symptoms have been well controlled and lung function stable for
≥3 months.
• No respiratory infection, patient not travelling, not pregnant.

3. Prepare for step-down;


• Record the level of symptom control and consider risk factors.
• Make sure the patient has a written asthma action plan.
• Book a follow-up visit in 1-3 months.

4. Step down through available formulations;


• Stepping down ICS doses by 25–50% at 3 month intervals is feasible and
safe for most patients.

5. Stopping ICS is not recommended in adults with asthma.

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SLIDE 39 Non-pharmacological interventions
1. Avoidance of tobacco smoke exposure;
• Provide advice and resources at every visit; advise against exposure of
children to environmental tobacco smoke (ETS) in house, car, etc.
2. Physical activity;
• Encouraged because of its general health benefits. Provide advice about
exercise-induced bronchoconstriction.
3. Occupational asthma;
• Ask patients with adult-onset asthma about work history. Remove
sensitizers as soon as possible. Refer for expert advice, if available.
4. Avoid medications that may worsen asthma;
• Always ask about asthma before prescribing NSAIDs or beta-blockers.
5. Breathing techniques (no specific technique);
• May be a useful supplement to asthma medications.
6. (Allergen avoidance);
• (Not recommended as a general strategy for asthma).


SLIDE 40 Indications for considering referral
1. Difficulty confirming the diagnosis of asthma;
• Symptoms suggesting chronic infection, cardiac disease etc.
• Diagnosis unclear even after a trial of treatment.
• Features of both asthma and COPD, if in doubt about treatment.
2. Suspected occupational asthma;
• Refer for confirmatory testing, identification of sensitizing agent, advice
about eliminating exposure, pharmacological treatment.
3. Persistent uncontrolled asthma or frequent exacerbations;
• Uncontrolled symptoms or on-going exacerbations or low FEV1 despite
correct inhaler technique and good adherence with Step 4.
• Frequent asthma-related health care visits.
4. Risk factors for asthma-related death;
• Near-fatal exacerbation in past.
• Anaphylaxis or confirmed food allergy with asthma.
5. Significant side-effects (or risk of side-effects);
• Significant systemic side-effects.
• Need for oral corticosteroids long-term or as frequent courses.
6. Symptoms suggesting complications or sub-types of asthma;
• Nasal polyposis and reactions to NSAIDS (may be aspirin exacerbated
respiratory disease).
• Chronic sputum production, fleeting shadows on CXR (may be allergic
bronchopulmonary aspergillosis).
7. Additional reasons for referral in children 6-11 years;
• Doubts about diagnosis, e.g. symptoms since birth.
• Symptoms or exacerbations remain uncontrolled.
• Suspected side-effects of treatment, e.g. growth delay.
• Asthma with confirmed food allergy.

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SLIDE 41 1. Check adherence with asthma medications Poor adherence;
• Is very common: it is estimated that 50% of adults and children do not take
controller medications as prescribed.
• Contributes to uncontrolled asthma symptoms and risk of exacerbations
and asthma-related death.

2. Contributory factors;
• Unintentional (e.g. forgetfulness, cost, confusion) and/or
• Intentional (e.g. no perceived need, fear of side-effects, cultural issues,
cost).

3. How to identify patients with low adherence;


• Ask an empathic question, e.g. “Do you find it easier to remember your
medication in the morning or the evening?”, or “Would you say you are taking it
3 days a week, or less, or more?”
• Check prescription date, label date and dose counter.
• Ask patient about their beliefs and concerns about the medication.

SLIDE 42 Strategies to improve adherence in asthma


Only a few interventions have been studied closely in asthma and found to be
effective for improving adherence;
• Shared decision-making.
• Simplifying the medication regimen (once vs twice-daily).
• Comprehensive asthma education with nurse home visits.
• Inhaler reminders for missed doses.
• Reviewing patients’ detailed dispensing records.

SLIDE 43 Investigations in patients with severe asthma


1. Confirm the diagnosis of asthma;
• Consider alternative diagnoses or contributors to symptoms, e.g. upper
airway dysfunction, COPD, recurrent respiratory infections.

2. Investigate for co-morbidities;


• Chronic sinusitis, obesity, GERD, obstructive sleep apnoea, psychological or
psychiatric disorders.

3. Check inhaler technique and medication adherence.

4. Investigate for persistent environmental exposure;


• Allergens or toxic substances (domestic or occupational).

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Management of severe asthma
SLIDE 44
1. Optimize dose of ICS/LABA;
• Complete resistance to ICS is rare.
• Consider therapeutic trial of higher dose.

2. Consider low dose maintenance oral corticosteroids;


• Monitor for and manage side-effects, including osteoporosis.

3. Add-on treatments without phenotyping;


• Theophylline, LTRA – limited benefit.
• Tiotropium – not yet approved for asthma by a major regulator.

4. Phenotype-guided treatment;
• Sputum-guided treatment to reduce exacerbations and/or steroid dose.
• Severe allergic asthma: suggest add-on anti-IgE treatment (omalizumab).
• Aspirin-exacerbated respiratory disease: consider add-on LTRA.

5. Non-pharmacological interventions;
• Consider bronchial thermoplasty for selected patients.
• Comprehensive adherence-promoting program.


SLIDE 45 Managing exacerbations in primary care
Principals;
1. Repetitive bronchodilator with rapid-acting ß2-agonist.
2. Oxygen supplementation.
3. Systemic glucocorticosteroids.
4. According to severity of asthma exacerbations.
5. Aims;
• Prevent death from acute respiratory failure.
• Relieve airway obstruction.
• Relieve hypoxaemia.
• Restore patient’s clinical condition & lung function to normal as soon as
possible.
• Maintain optimal lung function & prevent early relapse.
• Plan avoidance of future relapse.
• Develop an action plan in case of further exacerbation.

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SLIDE 46 Managing exacerbations in primary care

SLIDE 47 Managing exacerbations in primary care


Systemic glucocorticosteroids;
• Speed resolution of exacerbations.
• Prevent early relapse.
• IV Hydrocortisone 200 mg or IV Methylprednisolone 40 mg.
• Oral glucocorticosteroids as effective as IV & preferred because less invasive &
less expensive.
• Oral glucocorticosteroids require at least 4 hours to produce clinical
improvement.
• Oral glucocorticosteroids dose of 0.5 – 1 mg/kg for 3 – 5 days (children) or 7
days (adult).

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SLIDE 48 Identify patients at risk of asthma-related death
1. Patients at increased risk of asthma-related death should be identified;
• Any history of near-fatal asthma requiring intubation and ventilation.
• Hospitalization or emergency care for asthma in last 12 months.
• Not currently using ICS, or poor adherence with ICS.
• Currently using or recently stopped using OCS (indicating the severity of
recent events).
• Over-use of SABAs, especially if more than 1 canister/month.
• Lack of a written asthma action plan.
• History of psychiatric disease or psychosocial problems.
• Confirmed food allergy in a patient with asthma.
2. Flag/Tag these patients for more frequent review.


SLIDE 49 Written asthma action plans
1. All patients should have a written asthma action plan;
• The aim is to show the patient how to recognize and respond to worsening
asthma.
• It should be individualized for the patient’s medications, level of asthma
control and health literacy.
• Based on symptoms and/or PEF (children: only symptoms).
2. The action plan should include;
• The patient’s usual asthma medications.
• When/how to increase reliever and controller or start OCS.
• How to access medical care if symptoms fail to respond
3. Why?
• When combined with self-monitoring and regular medical review, action
plans are highly effective in reducing asthma mortality and morbidity.


SLIDE 50 Written asthma action plans – medication options
1. Increase inhaled reliever;
• Increase frequency as needed.
• Adding spacer for pMDI may be helpful.
2. Early and rapid increase in inhaled controller;
• Up to maximum ICS of 2000mcg BDP/day or equivalent.
• Options depend on usual controller medication and type of LABA.
3. Add oral corticosteroids;
• Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days.
• Children: 1-2mg/kg/day up to 40mg, usually 3-5 days.
• Morning dosing preferred to reduce side-effects.
• Tapering not needed if taken for less than 2 weeks.

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SLIDE 51 Written asthma action plans

SLIDE 52 Follow-up after an exacerbation


1. Follow up all patients regularly after an exacerbation, until symptoms and lung
function return to normal;
• Patients are at increased risk during recovery from an exacerbation.
2. The opportunity;
• Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma management.
3. At follow-up visit(s), check;
• The patient understands of the cause of the flare-up.
• Modifiable risk factors, e.g. smoking.
• Adherence with medications, and understanding of their purpose.
• Inhaler technique skills.
• Written asthma action plan.

SLIDE 53 Symptom patterns in children ≤5 years

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SLIDE 54 Features suggesting asthma in children ≤5 years


SLIDE 55 Common differential diagnoses of asthma in children ≤5 years

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SLIDE 56 Common differential diagnoses of asthma in children ≤5 years
(continued)

SLIDE 57 GINA assessment of asthma control in children ≤5 years (appendix


1: Management of asthma at primary care level)

SLIDE 58 Control-based asthma management cycle in children ≤5 years

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SLIDE 59 Stepwise approach to control symptoms and reduce risk
(children ≤5 years)

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SLIDE 60 Stepwise approach – key issues (children ≤5 years)

1. Assess asthma control;


• Symptom control, future risk, comorbidities.

2. Self-management;
• Education, inhaler skills, written asthma action plan, adherence.

3. Regular review;
• Assess response, adverse events, establish minimal effective treatment.

4. Other;
• (Where relevant): environmental control for smoke, allergens, indoor or
outdoor air pollution.

SLIDE 61 Step 1 (children ≤5 years) – as-needed inhaled SABA

1. Preferred option: as-needed inhaled SABA;


• Provide inhaled SABA to all children who experience wheezing episodes.

2. Other options;
• Oral bronchodilator therapy is not recommended (slower onset of action,
more side-effects).
• For children with intermittent viral-induced wheeze and no interval
symptoms, if as-needed SABA is not sufficient, consider intermittent ICS.
Because of the risk of side-effects, this should only be considered if the
physician is confident that the treatment will be used appropriately.

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SLIDE 62 Step 2 (children ≤5 years) – initial controller + as-needed SABA

1. Indication;
• Child with symptom pattern consistent with asthma, and symptoms not
well-controlled, or ≥3 exacerbations per year.
• May also be used as a diagnostic trial for children with frequent wheezing
episodes.

2. Preferred option: regular daily low dose ICS + as-needed inhaled SABA;
• Give for ≥3 months to establish effectiveness, and review response.

3. Other options depend on symptom pattern;


• (Persistent asthma) – regular leukotriene receptor antagonist (LTRA) leads
to modest reduction in symptoms and need for OCS compared with placebo.
• (Intermittent viral-induced wheeze) – regular LTRA improves some
outcomes but does not reduce risk of exacerbations.
• (Frequent viral-induced wheeze with interval symptoms) – consider
episodic or as-needed ICS, but give a trial of regular ICS first.

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SLIDE 63 Step 3 (children ≤5 years) – medium dose ICS + as-needed inhaled
SABA

1. Indication;
• Asthma diagnosis and symptoms not well-controlled on low dose ICS.
• First check symptoms are due to asthma, and check adherence, inhaler
technique and environmental exposures.

2. Preferred option: medium dose ICS with as-needed inhaled SABA;


• Review response after 3 months.

3. Other options;
• Consider adding LTRA to low dose ICS (based on data from older children).

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SLIDE 64 Step 4 (children ≤5 years) – refer for expert assessment
1. Indication;
• Asthma diagnosis and symptoms not well-controlled on medium dose ICS.
• First check symptoms are due to asthma, and check adherence, inhaler
technique and environmental exposures.
2. Preferred option: continue controller treatment and refer for expert assessment.
3. Other options (preferably with specialist advice);
• Higher dose ICS and/or more frequent dosing (for a few weeks).
• Add LTRA, theophylline or low dose OCS (for a few weeks only).
• Add intermittent ICS to regular daily ICS if exacerbations are the main
problem.
• ICS/LABA not recommended in this age group.


SLIDE 65 ‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years

§ This is not a table of equivalence.


§ A low daily dose is defined as the dose that has not been associated
with clinically adverse effects in trials that included measures of safety.

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SLIDE 66 Choosing an inhaler device for children ≤5 years

SLIDE 67 Initial assessment of acute asthma exacerbations in children ≤5 years

*Any of these features indicates a severe exacerbation.


**Oximetry before treatment with oxygen or bronchodilator.

Take into account the child’s normal developmental capability.

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SLIDE 68 Indications for immediate transfer to hospital for children ≤5 years


SLIDE 69 Initial management of asthma exacerbations in children ≤5 years

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Management of acute exacerbation at primary care level
SLIDE 70

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TOPIC 2

UPDATE ON
MANAGEMENT
OF ASTHMA AND
ASSESSMENT TOOL

Training Module For


Health Care Providers

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TOPIC 2: UPDATE ON MANAGEMENT OF ASTHMA AND
ASSESSMENT TOOL
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Learning objective
• Brief update for health care provider on asthma assessment tools, management target of asthma
treatment and control.

UPDATE ON MANAGEMENT OF ASTHMA AND ASSESSMENT TOOL

SLIDE 1 Definition of Asthma


• Asthma – chronic disease caused by inflammation of the airways.
• Definition - Asthma is a heterogeneous disease, usually characterized
by chronic airway inflammation. It is defined by the history of respiratory
symptoms such as wheeze, shortness of breath, chest tightness and cough
that vary over time and in intensity, together with variable expiratory airflow
limitation.

SLIDE 2 Poorly managed asthma


• 52 year-old taxi driver
• Asthma since infancy
• Up to age 13 years old:
– Theophylline syrup
– Prednisone syrup as needed
– Salbutamol pMDI 3X/day & as
needed
• Pulmonary tuberculosis!! Spinal
surgery for osteoporosis and scoliosis
• 42 to 52 years old
– FEV1 45% predicted; minimal
reversibility
– Budesonide 800g/day pMDI
– Salbutamol pMDI as needed
– Salmeterol 50µg bid pMDI

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Reasons for Poor Control in Asthma
1. The wrong diagnosis
2. Incorrect choice of inhaler, poor technique
3. Smoking
4. Co-morbid rhinitis
5. Individual variation in response to treatment
6. Patients’ beliefs and adherence
* Lack of treatment adherence is a major problem for asthma management


SLIDE 4 Asthma and Allergic Rhinitis: 2 Related Conditions linked by 1
Common Airway
1. Frequently overlapping conditions
2. Involvement of similar tissues
3. Common inflammatory processes
• Common inflammatory cells
• Common inflammatory mediators


SLIDE 5 Poor Adherence Factors

I Unintentional non-adherence
1. Inadequate understanding of disease
2. Poor comprehension of drug regimen or inhaler technique5
3. Simple forgetfulness
4. Socioeconomic factors

II Intentional non-adherence
1. Patient’s understanding of health benefits
2. Ethnic/cultural differences

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SLIDE 6 Rationale for Development
1 Asthma management guidelines now recommend the early use of inhaled
steroids in the majority of patients with asthma
2. Patients remaining symptomatic while on inhaled steroid treatment may
need a change in therapy. Options:
• Increase dose of ICS
• Switch ICS/LABA combination therapy
• What are the benefits of combining an inhaled steroid with an inhaled
long-acting bronchodilator ?
• More effective than increasing the inhaled steroid dose
• Greater improvements in lung function, symptom control, reduction in
exacerbation and quality of life


SLIDE 7 What does control really mean?

New 2010 GINA guideline definition of control – a gold standard

Characteristic Controlled (all of the following)

Daytime symptoms Twice or less per week

Limitations on activities None

Nocturnal symptoms or awakenings None

Need for reliever/‘rescue’ treatment Twice or less per week

Lung function Normal


SLIDE 8 Using the adult ACT score (appendix 1 chapter topic 1)

ACT score Level of control


20 - 25 Good
15 - 19 Inadequate
10 - 14 Poor
5-9 Very Poor

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SLIDE 9 Goal of management of asthma

Overall
asthma
control

Achieving Reducing
CURRENT FUTURE
CONTROL RISK

Defined Defined
by by

Symptoms Reliever Instability / Exacerbations


use worsening

Loss of Adverse
Activity Lung lung effects of
function function medication


SLIDE 10 Outcome: Tampin Health Clinic 2009 – 2012


SLIDE 11 Conclusions
1. Poor asthma control worsens patient’s quality of life
2. Deaths and hospital costs reduced with improved control
3. Control can be achieved in line with guidelines, benefiting patient’s quality
of life
4. Asthma control instruments have predictive validity
5. Poor asthma control score associated with:
• Big impact on patient’s life
• Increased exacerbations, admissions and doctor visits

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TOPIC 3

ASSESSMENT
AND MONITORING
ASTHMA AND
CLINICAL ACTION
PLAN

Training Module For


Health Care Providers

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TOPIC 3: ASSESSMENT AND MONITORING ASTHMA
AND CLINICAL ACTION PLAN
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Learning objective
• Update on the latest GINA 2014 classification for adult and paediatric group (age below 5 years old),
asthma control test (ACT) monitoring for adult and children (4 to 11 years old), normogram for adult and
paediatric group and clinical action plan for adult and paediatric group which are the most important
tools upon discharging patient.
• All the monitoring tools are updated and can be used for the assessment, monitoring and adjusting the
medication dose for asthmatic patient. Paramedic may use these tools during triaging the patient and
it is useful in managing the asthma controlled level and also emergency cases.

ASSESSMENT AND MONITORING ASTHMA AND CLINICAL ACTION PLAN

SLIDE 1 1. GINA : Adult & pediatric (appendix 1 – chapter 1, topic 1)


2. Asthma Control Test (ACT) : Adult & pediatric (appendix 1 – chapter 1, topic 1)
3. PEFR normogram: Adult & pediatric (appendix 1 – chapter 1, topic 3)
4. Clinical action plan : Adult & pediatric


SLIDE 2 Global Initiative for Asthma Management (GINA)

The assessment of asthma control should include control of clinical


manifestations and control of expected future risk such as exacerbation,
accelerated decline in lung function and side effects of treatment
A. Assessment of current clinical control (preferably over the past 4 weeks)
B. Assessment of future risk ( Risk of exacerbations, instability, rapid decline
in lung function and side effects ):
• Features of increase risk of adverse event in the future : poor clinical
control, frequent exacerbations in past years, ever admissions to
critical care for asthma, low FEV1, exposure to cigarette smoke, high
dose medications

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SLIDE 3 PEFR normogram: Adult


SLIDE 4 PEFR normogram: Pediatric

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50

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SLIDE 5 Clinical action plan: Adult and adolescent
  SIHAT RAWATAN   BERWASPADA RAWATAN   BAHAYA RAWATAN
  • Tidak batuk Gunakan Inhaler   Bila ada salah satu tanda-tanda Ikut peraturan berikut   Dapatkan rawatan Jumpa Doktor SEGERA
  • Tidak sesak nafas Pencegah setiap hari.   berikut : selama 7 -14 hari.   dengan Segera
  • Tidak sesak dada Inhaler Pencegah • Terbangun dari tidur pada waktu Jika sembuh sila   • Serangan sesak Jangan tunggu
  • Tiada pernafasan berbunyi ______sedutan 2 kali malam disebabkan serangan semput. kembali kepada Zon 1   nafas yang teruk Telefon ambulan 999
  • Tidak terbangun pada waktu / hari. • Serangan semput lebih dari 2 kali (zon hjau).   • Tidak boleh  
  malam kerana asma semput Z seminggu pada waktu siang. Z bercakap dengan Inhaler Pelega:
  (Bacaan “peak flow” 80-100% O • Penggunaan ubat pelega lebih dari Inhaler Pelega: O lancar. 2 Sedutan setiap 10
  N 2 kali seminggu. 2 sedutan SAHAJA bila N • Serangan semput minit sehingga sampai
Z   • Aktiviti atau senaman terhad perlu dan 4–6 jam   yang teruk dan ke hospital atau jumpa
O   disebabkan serangan semput. Tanda- sekali, tidak lebih dari   • menakutkan. doktor.
N K tanda selsema /demam. 12 sedutan sahaja. M • Ubat Pelega tidak
  U (Bacaan “peak flow” 50-80%) E • Melegakan
H N Inhaler Pencegah ____ R • Langsung
I I sedutan 2 kali / hari A
J N H (Bacaan “peak
A G flow” kurang 50%)
U Sebelum senaman atau ada Inhaler Pelega:   Jika tiada kelegaan
tanda-tanda semput ringan 2 Sedutan SAHAJA bila dengan rawatan di
perlu atas :
Jumpa Doktor

Clinical action plan: Pediatric


SIHAT RAWATAN TIDAK SIHAT RAWATAN TIDAK SIHAT RAWATAN
• Anak anda SIHAT jika: Gunakan Inhaler • Alami bunyi di dada, batuk Bila ada selsema atau gejala asma A)  TERUK Jumpa Doktor
• Tidak batuk atau berbunyi di Pencegah setiap hari. atau ketat dada bertambah buruk (tiada sesak • Alami salah satu SEGERA
dada atau ketat dada di waktu (Hanya jika dipreskripsi • Alami batuk, ketat dada nafas) : daripada tanda- Jangan tunggu
malam oleh doktor): dan berbunyi di dada Ambil Inhaler Pelega tanda berikut: Telefon ambulan
• Tidak batuk, berbunyi di dada   apabila bangun di waktu Nama ubat: _________ ketat dada, batuk 999
atau ketat dada sewaktu Inhaler Pencegah pagi Dos : _________ atau sesak nafas  
bangun pagi atau siang hari   • Perlukan tambahan ubat Kekerapan: • Perlukan ubat pelega Ubat
• Tidak ada tanda-tanda lelah / Nama ubat: pelega _________ sekurang - kurangnya kecemasan

MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
asma bila bermain atau aktif __________ Z • Alami tanda -tanda batuk, Kali / hari 3 jam sekali (Inhaler Pelega):
Z • Tidak memerlukan ubat pelega Dos: _______ ketat dada dan berbunyi Ambil Inhaler Pencegah: Z   Ubat: MDI
O
O lebih dari 3 kali seminggu Kekerapan di dada (Hanya jika dipreskripsi oleh doktor) O B) MERBAHAYA Salbutamol
N
N (malahan kegunaan waktu _______kali / hari • PEFR:____ L/min Nama ubat: N • Tanda-tanda di atas  
 
  bermain) _________   menjadi semakin Dos :
K
H • PEFR:___ L/min Dos: ______ M teruk ______
U
I Kekerapan: E • Masih sesak nafas 6 sedutan
N
J _________ R atau ketat dada setiap 20 minit
I
A kali / hari A walaupun selepas semasa
N
U Bila gejala asma anak anda bertambah H menggunakan ubat perjalanan ke
G
pulih, ambil semula dos sebelum ini pelega hospital
semasa sihat. • Sesak nafas semakin
teruk, tidak boleh
bercakap dan bibir
menjadi biru
• PEFR:______L/min
Sebelum senaman atau ada   Jika tiada kelegaan dengan      
tanda-tanda semput ringan rawatan di atas: Jumpa
Doktor

11/26/14 3:16 PM
TOPIC 4

MANAGEMENT
OF CHILDHOOD
ASTHMA
ACCORDING TO
MALAYSIA CPG

Training Module For


Health Care Providers

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TOPIC 4: MANAGEMENT OF CHILDHOOD ASTHMA
ACCORDING TO MALAYSIA CPG
TRAINING MODULE FOR HEALTH CARE PROVIDERS
Learning Objective
• Brief regarding the latest management flow of asthma treatment in paediatric which based on the
latest Asthma Management in children (Malaysia).
• Clinical assessment, evaluation of asthma control and long term management step of medication is
updated.
• Monitoring instrument use in children such as peak flow meter (PFM) and Pulmonary function test
(Spirometry) is mentioned in this topic.
• Drug dosage formulary and inhaler use is illustrated in this topic for better demonstration and
understanding

MANAGEMENT OF CHILDHOOD ASTHMA ACCORDING TO MALAYSIA CPG

SLIDE 1 Learning outcomes


1. Understand about pre - school wheeze
2. Diagnosing asthma in children
3. Able to classify asthma severity upon diagnosis and treatment
4. Understand about asthma control
5. Understand stepwise approach of treatment
6. Able to classify and recognize severity of asthma exacerbation

Overview of Pathogenesis of Asthma


SLIDE 2

Overall
asthma
control

Pathogenesis

Management

Genetic Environment Preventive


measures

Airway inflammation Asthma


Controllers

AHR Baseline airway obstruction

Triggers:
• Virus Environmental
controls
• Allergens
• Irritants

Asthma exacerbation Asthma relievers

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Airway Remodeling (refer to appendix 1: Chapter 1, Topic 3 ; illustrative regarding
the chronic airways inflammation and airway remodeling)
• Structural changes seen in patient with respiratory disease
• Main components
1. Epithelial damage and disruption
2. Goblet cells hyperplasia
3. Increase number of sub mucous gland
4. Deposition if structural protein into the reticular
• basement membrane
• Hypertrophy and hyperplasia of smooth muscle
• Sub epithelial fibrosis
• Increased vascularization


SLIDE 4 Differential diagnosis of asthma

Upper airway disease Allergic Rhinitis / Rhinosinusitis / Sinusitis


• Foreign body in trachea and bronchus
• Vocal cord dysfunction
• Vascular rings
Obstruction of Large Airways • Laryngeal webs
• Laryngo-tracheomalacia, tracheal stenosis,
bronchostenosis
• Enlarged lymph nodes
• Viral Bronchiolitis
• Obliterative bronchiolitis
• Bronchiectasis
Obstruction of Small Airways • Heart disease/ heart failure
• Chronic lung disease / Bronchopulmonary
dysplasia
• Cystic fibrosis
• Recurrent cough due to GORD
Other causes • Aspiration from dysfunctional swallowing
• Immunodeficiency
• Allergic Rhinitis / Rhinosinusitis
Upper airway disease
• Sinusitis

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SLIDE 5 Asthma wheeze

CHILDHOOD
WHEEZING
(50%)

Transient
early Persistent Late onset
N= 1246 wheeze wheeze wheezes
(20%) (15%) (15%)

Wheeze with ARI YES NO


YES
< 3 years

Persistent
wheeze NO YES YES

Ref: Martinoz FD New England J Med 1995: 332:133.8


SLIDE 6 Pattern of wheeze

Term Definition
Episodic viral wheeze Wheeze during discrete times in association with clinical
evidence of viral cold absence of wheeze between episodes

Multiple trigger wheeze Wheeze that shows discrete exacerbations


Symptomatic in between episodes

Duration of wheeze • Commenced before the age of three years and


Transient wheeze retrospectively found to disappear by 6 years old.
• Transient wheeze can be episodic wheeze or multiple
trigger wheeze

Temporal pattern of wheeze


Term Definition
Persistent wheeze Symptoms (retrospectively) to have continued until the age
of > 6 years old
May be episodic or multiple trigger wheeze

Late onset of wheeze Starts after the age of three years.


Late onset wheeze may be episodic or multiple trigger
wheeze

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SLIDE 7 Evaluation of background of newly diagnosed asthma

Intermittent Asthma

1. Daytime symptoms < once a week


2. Nocturnal symptoms ≤ twice a month
3. No exercise induced symptoms.
4. Brief exacerbations not affecting sleep and activity

Persistent Asthma

• Daytime symptoms ≥ once a week


• Nocturnal symptoms > twice a month
Mild • Exacerbation affecting sleep and activity once a month.
• PEFR or FEV1 >80%
• Exercise or activity induced asthma

• Daytime symptoms daily


• Nocturnal symptoms > once a week
Moderate • Exacerbation affecting sleep and activity ≥ twice a month
• PEFR or FEV1 60% - 80%
• Exercise or activity induced asthma

• Daily daytime symptoms


• Daily nocturnal symptoms
Severe • Exacerbation affecting sleep and activity frequently
• PEFR or FEV1 < 60%
• Exercise or activity induced asthma


SLIDE 8 Long term management of Persistent Asthma

INTERMITTENT
STEP 1
Intermittent 2 AGONIST

STEP 2 Mild
persistent Low dose inhaled steroids or leukotriene antagonist
asthma

STEP 3 Moderate
persistent Moderate dose of inhaled corticosteroids
asthma

STEP 4 severe
Moderate dose of inhaled corticosteroids
persistent
asthma combination / high dose inhaled corticosteroids

STEP 5 severe
persistent Add theophylline / alternate day corticosteroids
asthma

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SLIDE 9 Evaluation of asthma control

A. Symptom control Level of asthma symptom control

Well Partly
In the past 4 weeks, the child had: Uncontrolled
controlled controlled

Daytime asthma Yes No


symptoms for more
than few minutes,
more than once /
week

Any activity limitation Yes No


due to asthma? (runs,
plays less than other None of
children) 1 – 2 of these 3 – 4 of these
these

Reliever needed* Yes No


more than once a
week?

Any night waking or Yes No


night coughing due to
asthma

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SLIDE 10 Stepwise approach – key issues (children ≤ years)

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SLIDE 11 Management Approach Based On control
REDUCE

REDUCE
Level of Control Treatment options
Controlled Maintain and find lowest controlling step
Partially controlled Consider stepping up to gain control

INCREASE
Uncontrolled Step up until controlled
Exacerbations Treat as exacerbations

INCREASE


SLIDE 12 Long Term Follow-up

• Frequency and severity of acute exacerbation


• Morbidity secondary to asthma
• Assessment - asthma • Quality of life
control based • Peak Expiratory Flow Rate (PEFR) or FEV1 monitoring
• Compliance • Frequency
• Asthma education • Technique
• Understanding asthma in childhood
• Reemphasize compliance to therapy
• Written asthma action plan


SLIDE 13 Pulmonary Function Test: Spirometry
1. At the time of initial assessment
2. After treatment initiated and stabilization of symptoms
3. To document a near normal attainment of lung function
4. When there is loss of control
5. At least yearly to document maintenance of lung function
6. More frequent if clinically indicated


SLIDE 14 Spirometry
Three basic measurements:
1. Forced Vital Capacity (FVC)
2. Forced Expiratory Volume In One Second (FEV1)
3. Ratio of FEV1/FVC (Forced Expiratory Ratio FER or FEV1 %)

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SLIDE 3 Peak Flow Meter
1. A tool for monitoring ongoing monitoring
2. Useful for children who can perform Peak Flow Meter
3. To detect early changes in disease states that require treatment
4. Evaluate responses to changes in therapy
5. Afford a quantitative measure of impairment


SLIDE 16 Calculations

Peak flow rate (PEFR) measurement


1. Based on patient’s height and gender,
• identify the predicted PEFR value
• i.e. x (Refer PEFR for Malaysian children)
2. Take the best patient’s PEFR measurement i.e. y
3. Calculation PEFR percentage: ( y/ x ) x 100% = z %
4. Classification of severity (refer Asthma severity and control)

Bronchodilator response
1. Best pre- bronchodilator PEFR i.e. a
2. Best post-bronchodilator PEFR i.e. b
3. Calculate percentage of bronchodilator response
(b-a) x 100
=c%
a


SLIDE 16 Reliever
Relieve respiratory symptoms
1. Reliever : intermittent short acting
B2 agonist drug of choice
2. Oral bronchodilator discouraged


SLIDE 17 Preventer
1. Reduce airway inflammation inhaled
corticosteroids treatment of choice
2. Leukotrienes antagonist
3. Age of child
4. Asthma wheeze phenotypes
5. Frequency and severity of symptoms

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SLIDE 18 Controller medications

Controller medication: Shown to


have better control with no night
symptoms, no increase in short
acting B2 agonist use.
1. Seretide (Flixotide +
Salmeterol)
2. Symbicort (Pulmicort)


SLIDE 19 Inhaler devices according to age

Children aged 0 - 6 years Metered dose inhaler + spacer with facemask

Children aged > 6 years • Metered dose inhaler + spacer with facemask
• Metered dose inhaler + spacer with mouthpiece
• Dry powder inhaler
• Breath device (> 8 years)


SLIDE 20 Assessment of asthma exacerbations
1. History and physical examination is an important tool to assess the
severity of asthma
2. The time of onset of the exacerbation
3. To identify underlying cause of the present exacerbation such as URTI,
cigarette smoker and etc
4. Severity of symptoms including exercise and sleep disturbance
5. All current asthma medications that the patient has been on prior to the
exacerbation
6. The dose of preventer therapy taken during the deterioration
7. Patient’s response to therapy during the exacerbation such as to the dose
of bronchodilator or oral steroids taken.
8. Risks factors: Past history of hospitalizations, intensive care, ER visits
due to exacerbations

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SLIDE 21 Assessment of severity of acute asthma

Mild Moderate Severe


Altered consciousness No No Yes
Physical exhaustion No No Yes
Talks in Sentences Phrases Words
Central cyanosis Absent Absent Present
Rhonchi on auscultation Present Present Absent

Accessory muscle use Absent Moderate Marked


Sternal recession Absent Moderate Marked
Iniatial PEFR >60% 40-60% <40%
Pulse oximetry in air >93% 91-93% <90%


SLIDE 22 Management based on severity
Severity Treatment Observation Plan
Mild Nebulized salbutamol or MDI Observe for 60 minutes Discharge with improved long
salbutamol + spacer (4 – 6 puffs, after last dose term treatment and asthma
< 6 yo) and 8 – 12 puffs, > 6 yo) plan
Oral prednisolone 1 mg / kg Short course of oral steroid
/ day (max: 60 mg perday for (3 – 5 days)
3 – 5 days as moderate)
Regular bronchodilator 4 – 6
hourly for few days then PRN
Early TCA 2 – 4 weeks
Review after 20 minutes, if no
improvement treat as moderate
Moderate Nebulised salbutamol ± ipratropium Observe for 60 minutes Discharge with improved long
bromide (3 at 20 minutes intervals), after last dose term treatment and asthma
oxygen at 8 liters/ min via face plan
mask and Oral prednisolone 1 mg Short course of oral steroid
/ kg / day (max: 60 mg perday for (3 – 5 days)
3 – 5 days
Regular bronchodilator 4 – 6
hourly for few days then PRN
Early TCA 2 – 4 weeks
Admit if no improvement
Severe Nebulised β2 agonist every 20 Continue observation and
/ life minutes / continous for 1 hour. review
threatening Ipratropium bromide 3x every
20 minutes
Oxygen (face mask 8 liters)
Steroids (oral / IV)
IV salbutamol cntinous infusion
1 – 5mic/kg/min ± loading
15 mic/ kg over 10 minutes
Subcutaneous β2 agonist
(terbutraline / adrenaline)
IV bolus magnesium
sulphate 50% 0.1 ml/kg (50mg/kg)
over 20 minutes
Consider HDU / ICU admission
± IV aminiphylline
± Ventilation
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CHILDHOOD
WHEEZING
(50%)


SLIDE 23 High risk of asthma group

Poor asthma On three


Bronchodilator reliance
control medications

Nocturnal Undertreated Frequent ER visits ICU / HDU admission


symptoms and poor adherence and admissions and ventilations

Immediate asthma symptoms or


Poor perceivers and denials hypersensitivity to drugs or food


SLIDE 24 Conclusion
1. Correct diagnosis
2. Classification of severity
3. Classification of asthma control
4. Appropriate medication
5. Recognizing high risk asthmatics

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TOPIC 5

STEPWISE
APPROACH, INHALER
TECHNIQUE AND
PHARMACOTHERAPY
IN ASTHMA
MANAGEMENT

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Care Providers

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TOPIC 5: STEPWISE APPROACH, INHALER TECHNIQUE
AND PHARMACOTHERAPY IN ASTHMA MANAGEMENT
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Learning Objective
• List of controller and preventive medication are mentioned in this topic for better understanding.
Side effect of each medication is stated in this module for better practice and learning purposes.
• Adjust medication & dosage based to the level of asthma management. Learn the right technique in
using inhaler and peak flow meter with better illustrtive.

INHALER TECHNIQUE AND PHARMACOTHERAPY IN ASTHMA MANAGEMENT

SLIDE 1 Stepwise Approach

Goal Of Therapy : Control Of Asthma


For most asthmatic patients, the situation can be extremely well-controlled by
using the step-care approach as recommended by NAEPP in 2007
Koda-Kimble M.A., Young L.Y., Alldredge B.K., Corelli R.L., Guglielmo B.J., Kradjan
W.A. et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed. Lippincott
Williams & Wilkins. Philadelphia, Pennsylvania, USA.
Stepwise approach for managing asthma in youth > 12 years of age and adults

Persistent Asthma: Daily Medication


Intermittent
Consult with asthma specialist if Step 4 care or higher is required. Step up
Asthma
Consider consultation at Step 3 if needed
(first check
STEP 2 STEP 3 STEP 4 STEP 5 STEP 6
adherence,
Preferred: Preferred: Preferred: Preferred: Preferred: High-
Low-dose ICS Low-dose ICS Medium- High-dose dose ICS + LABA + environmental
Alternative: + LABA dose ICS + ICS + LABA oral corticosteroid control and
Cromolyn, OR LABA AND AND comorbid
STEP 1 conditions)
LTRA, Medium- Alternative: Consider Consider
Preferred: Step down if
Nedocromil dose ICS Medium- Omalizumab Omalizumab for
SABA PRN
or Alternative: dose ICS + for patients patients who have possible (and
Theophylline Low-dose either LTRA, who have allergies asthma is well
ICS + either Theophylline allergies controlled
LTRA, or Zileuton at least 3
Theophylline months)
or Zileuton
Each step: Patient education, environmental control and management of comorbidities.
Step 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Assess
(see notes). Control
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to
3 treatments at 20-minutes intervals as needed. Short course of oral systemic corticosteroids
may be needed.
• Use of SABA > 2 days a week for symptom relief (not prevention of IEB) generally indicates
inadequate control and the need to step up treatment.
Notes:
• The stepwise approach is meant to assist, not replace, the clinical decision making required to
meet individual patient needs.
• If alternative treatment is used and response is inadequate, discontinue it and use the preferred
treatment before stepping up.
• Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need
to monitor liver function. Theophylline requires monitoring of serum concentration levels.
• In step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA + Adapted from
either LTRA, theophylline or zileuton may be considered, although this approach has not been NAEPP 2007
studied in clinical trials.
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SLIDE 2 Goal Of Therapy : Control Of Asthma

This stepwise approach combining the four components of care in the


management of asthma that emphasizes pharmacological treatment is started
based on the classification of asthma severity

Koda-Kimble M.A., Young L.Y., Alldredge B.K., Corelli R.L., Guglielmo B.J., Kradjan
W.A. et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed.
Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.

CLASSIFICATION FEATURES

Intermittent • Symptoms less than once a week


• Brief exacerbations
• Nocturnal symptoms not more than twice a month
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20%

Mild Persistent • Symptoms more than once a week but less than once a day
• Exacerbations may affect activity and sleep
• Nocturnal symptoms more than twice a month
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20 – 30%

Moderate Persistent • Symptoms daily


• Exacerbations may affect activity and sleep
• Nocturnal symptoms more than once a week
• Daily use of inhaled short-acting β2-agonist
• FEV1 or PEF 60-80% predicted
• PEF or FEV1 variability > 30%

Severe Persistent • Symptoms daily


• Frequent exacerbations
• Frequent nocturnal asthma symptoms
• Limitation of physical activities
• FEV1 or PEF ≤ 60% predicted
• PEF or FEV1 variability > 30%

FEV1: forced expiratory volume in one second; PEF: peak expiratory flow.

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Goal Of Therapy : Control Of Asthma

Pharmacological treatment is based on the classification of adjusted (stepped


up or stepped down) according to level of asthma control (Appendix 1; Chapter
1; Topic 5)

Koda - Kimble M.A et al. (2009). Applied therapeutics: the clinical use of drugs.
9th ed. Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.

Stepped up and stepped down therapy using asthma medications, also known
as stepwise approach, can be done by gathering information from each
appointment with clinicians.

Yawn, B. P et al. (2007). Asthma treatment in a population-based cohort: putting


step-up and step-down treatment changes in context. Mayo Clin Proc, 82 (4),
414-421.


SLIDE 4 Asthma management

Stepwise approach is subdivided into increases or decreases in the dose


medications within the class used by the patient including the addition or change
of medication which will change the class of medications.

Stepped up change is further sub classified to either temporary or limited


such as burst of oral systemic corticosteroids (OSC) for 3 to 10 days during an
exacerbation or may be prescribed to improve longer-term control.

Yawn, B. P et al. (2007). Asthma treatment in a population-based cohort: putting


step-up and step-down treatment changes in context. Mayo Clin Proc, 82 (4),
414-421

Changes in the brands of ICS in therapeutic categories were compared as (Yawn


et al., 2007) listed in Table 3 which shows an estimated equipotent daily dose
for adults.

Global Initiative for Asthma (GINA): Global strategy for asthma management and
prevention updated 2010.

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SLIDE 5 Table 3: Estimated equipotent daily doses of inhaled corticosteroids for adults+

Drug Low daily Medium daily dose (µg) High daily dose (µg)++
dose (µg)

Beclomethasone 200 – 500 >500 – 1000 > 1000


dipropionate
Budesonide* 200 – 400 >400 – 800 > 800

Ciclesonide* 80 – 160 >160 – 320 >320

Flunisolide 500 – 1000 >1000 – 2000 >2000

Fluticasone 100 – 250 >250 – 500 >500


propionate
Mometasone 110 – 220 440 >440
furoate*
Triamcinolone 400 – 1000 >1000 – 2000 >2000
acetonide
+
Comparisons based upon efficacy data.
++
Patients considered for high daily doses except for short periods should be referred to
a specialist for assessment to consider alternative combinations of controllers. Maximum
recommended doses are arbitrary but with prolonged use are associated with increased risk of
systemic side effects.
* Approved for once-daily dosing in mild patients.

Notes
• The most important determinant of appropriate dosing is the clinician’s judgement of the
patient’s response to therapy. The clinician must monitor the patient’s response in terms of
clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose
of medication should be carefully titrated to the minimum dose required to maintain control,
thus reducing the potential for adverse effects.
• Designation of low, medium and high doses is provided from manufacturers’ recommendations
where possible. Clear demonstration of dose-response relationships is seldom provided or
available. The principle is therefore to establish the minimum effective controlling dose in
each patient, as higher doses may not be more effective and are likely to be associated with
greater potential for adverse events.
• As CFC preparations are taken from the market, medication inserts for HPA preparations
should be carefully reviewed by the clinician for the equivalent correct dosage.

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SLIDE 6 Asthma Management
In order to achieve asthma control, the following sequence of activities is proposed:
• First, for patients who do not take the medication for long-term control, assessment
of asthma severity should be taken in advance and then start pharmacotherapy
according to the severity.
• For patients who have been taking long-term control medications, the level of asthma
control needs to be evaluated and pharmacotherapy is stepped up if asthma is poorly
controlled on current therapy.
• However, before stepping the treatment up, patient’s compliance to medications,
technique of handling inhaler and environmental control measures should be reviewed.
• Depending on the initial level of severity or control, asthma control should be evaluated
in two to six weeks.
• In general, the level of asthma control should be classified by the most severe indicator
of impairment or risk.
• Risk domain is typically more closely related to morbidity among young children from
the impairment domain because young children are usually free of symptoms between
exacerbations.
• If spirometry shows poorer control than other measures of impairment, clinicians
should consider fixed obstacles and need to reassess the other steps.
• The pharmacotherapy should be stepped up if the fixed obstacles still fail to explain
the lack of control because low value of FEV1 is one predictor of exacerbations of
asthma as well as the history of exacerbations suggests poor asthma control.
• The clinicians also have to include the use of OSC and review plans for handling of asthma
exacerbations especially for patients who have a history of severe exacerbations.
• A review should be carried out on the patient’s adherence to drugs, technique of
inhaler, environmental control measures or whether there are new disclosure and
management of co-morbidities if a patient does not achieve asthma control by the
above actions.
• Pharmacotherapy can be stepped up one step in not well-controlled asthma or two
steps in very poorly controlled asthma if adherence and measures of environment
control are sufficient.
• For patients using alternative treatment at the initial of treatment, it is necessary
to discontinue it and use the preferred treatment option before stepping up
pharmacotherapy.
• The OSC short-term use can be considered to gain faster control for patients who
are experiencing an exacerbation at the time of assessment or whose asthma always
interrupts normal daily activities or sleep.
• Clinicians should consider an alternative diagnosis if lack of control persists, before
stepping up further.
• For patients experiencing the side effects of pharmacotherapy, different treatment
options should be considered.
• It is important to have regular follow up to maintain the asthma control because
asthma can change from time to time.
• Patients should be scheduled at 1- to 6-month intervals and it will depend on factors
such as the level of treatment required and the level or duration of asthma control.
• For well-controlled asthma for at least 3 months, clinicians should consider a step
down in pharmacotherapy.
• A step down in pharmacotherapy is necessary to identify the minimum therapy needed
to maintain good asthma control.
• However, there are only a few studies in guiding therapy reduction in pharmacotherapy
that should be gradual and closely monitored.
• In general, for every 3 months, the dose of ICS can be reduced from 25% to 50% of the
lowest possible dose.
• For those patients who have asthma symptoms during particular seasons (e.g.,
seasonal pollens, allergens or viral respiratory infections) or intermittent asthma for
the rest of the year, clinicians should consider seasonal periods of long-term daily
control of pharmacotherapy.
• This approach is not strictly assessed but closely monitored for two to six weeks after
pharmacotherapy is discontinued to assure sustainability control of asthma

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis and
Management of Asthma. US Department of Health and Human Services. NIH Publication
No. 08-5846.

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SLIDE 7 Pharmacotherapy In Asthma Management

Bronchial Asthma
• Airway inflammation
• Episodic, reversible bronchospasm
• Chronic inflammation that leads to marked bronchial hyper - reactivity or
hypersensitivity (cornerstone: inhaled corticosteroid, ICS)
• Exposure to allergen or trigger factors (extrinsic or intrinsic factors) →
stimulate a broncho - constrictive response
- Humidity, temperature changes, smoke, fumes, stress, emotional upset,
allergies, dust, food, some drugs
• Release of several mediators from IgE-sensitized mast cells and other cells
involved in immunologic responses
• Mast cells stimulate release of chemical mediators (histamines, cytokines,
serotonin, ECF-A (eosinophils))
• These chemical mediators stimulate:
- bronchial constriction
- mucous secretions
- inflammation
- pulmonary congestion


SLIDE 8 Goal Of Therapy : Control Of Asthma
Reduce impairment

• Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in


the daytime, in the night or after exertion)

• Require infrequent use (< 2 days a week) of inhaled SABA for quick relief of
symptoms (not including prevention of exercise-induced bronchospasm [EIB])

• Maintain (near) normal pulmonary function

• Maintain normal activity levels (including exercise and other physical activity and
attendance at school or work)

• Meet patients’ and families’ expectations of and satisfaction with asthma care

Reduce risk

• Prevent recurrent exacerbations of asthma and minimize the need for emergency
department visits or hospitalisations

• Prevent loss of lung function; for children, prevent reduced lung growth

• Provide optimal pharmacotherapy with minimal or no adverse effects of therapy

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SLIDE 9 General treatment principles in view to achieve these goals of therapy with four
major components of care in the management of asthma control including
1. measures of asthma assessment and monitoring;
2. education for a partnership in care;
3. control of environmental factors and co-morbid conditions that affect
asthma; and
4. medications

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis
and Management of Asthma. US Department of Health and Human Services. NIH
Publication No. 08-5846.


SLIDE 10 Previously GINA classified three major classes for asthma treatment:
1. ß-agonist such as salbutamol, salmeterol or terbutaline;
2. glucocorticoids such as beclomethasone ; and
3. (3) inhibitors of the cysteinyl-leukotriene (cLI) pathway such as montelukast,
zafirlukast or zileuton.

However, the asthma treatment was revised and classified as short-term


management (reliever) and long-term management (controller), where cLI was
put under controller (GINA, 2009).

Global Initiative for Asthma (GINA): Global strategy for asthma management and
prevention updated 2009. (2009).
1. Reliever drugs [short acting ß-agonist (SABA) such as salbutamol] are
delivered as inhalers and are usually adequate for mild intermittent asthma.
2. SABA is used because it can provide rapid ‘rescue’ for acute airway
obstruction
3. ICS, long acting ß-agonist (LABA) and cLI were classified as controller drugs
in addition to rescue medication and it is necessary for mild, moderate or
severe persistent asthma.
4. This is because the controller drugs would modify the airway environment;
hence reducing the number of acute airway narrowing in the more
symptomatic patients.

Silverman, E. S., Liggett, S. B., Gelfand, E. W., Rosenwasser, L. J., Baron, R. M., Bolk,
S. et al. (2001). The pharmacogenetics of asthma: a candidate gene approach.
The Pharmacogenomics Journal, 1, 27-37.


SLIDE 11 Controller medications
1. Keeps swelling and mucus from developing in the airways
2. Must be taken EVERY day even when not having symptoms
3. Inhaled corticosteroids (ICS’s) are the most common and effective way to
control asthma
4. Help prevent asthma exacerbations from developing.

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SLIDE 12 Anti-inflammatory - Glucocorticorsteroid

Remember
1. Steroids are meant to work over a period of time to reduce swelling of the
airways.
2. They must be used regularly to be effective.
Always take steroids exactly as your doctor directs, even when you feel better
or do not believe they are helping you. If you stop taking steroids, your breathing
can get worse, sometimes much worse.


SLIDE 13 Possible Side Effects

Systemic Steroids (taken by mouth as a pill; Inhaled Steroids


affects the entire body)
May notice after a few days: • Oral thrush (yeast infection of the
• Fluid retention mouth) and sore tongue
• Increased appetite • Hoarseness
May experience after several
months of use:
• Adrenal suppression (less able to handle
stress)
• Decreased resistance to infection (get
infections more easily)

May experience after several


months or years of use:
• Moon face
• Cataracts
• Excess facial hair
• Osteoporosis


SLIDE 14 Leukotrine Receptor Antagonists & Synthesis Inhibitors
1. Montelukast sodium (Singulair); Zafirlukast (Accolate)
2. Action - Decreases the inflammatory process
3. Use - prophylactic & maintenance drug therapy for asthma
4. Montelukast:
• New Leukotriene Receptor Antagonist
• Short T1/2 (2.5-5.5hours)
• Safe For Children Under 6 Years Old.
5. Leukotriene (LT) a chemical mediator that can cause inflammatory changes
in the lung.
• The group cysteinyl leukotrienes promote and increase in eosinophil
migration, mucus production, and airway wall edema, which result in
bronchoconstriction.
6. LT receptor antagonists & LT synthesis inhibitors (Leukotriene modifiers)
effective in reducing the inflammatory symptoms of asthma triggered by
allergic & environmental stimuli - Not for acute asthma

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SLIDE 15 Introduction
1. Bronchodilators are medications that:
• relax/dilates the bronchi and bronchial muscles
• decreasing resistance in the respiratory airway
• increasing airflow to the lungs
2. Relaxing these muscles makes the airways larger, allowing air to pass
through the lungs easier.
3. This helps people with asthma breathe better.

SLIDE 16 What kinds of bronchodilators are there?


1. Bronchodilators may be:


• Endogenous (originating naturally within the body) or
• Medications administered for the treatment of breathing difficulties
• Some bronchodilators also help clear mucus from the lungs and reduce
inflammation.
2. Many different kinds of bronchodilators are available.
3. They can be grouped according to how long they work (called short- and
long-acting drugs) or the way in which they widen or dilate the airways
beta-agonists, anticholinergics or theophyllines).
4. They can be grouped according to how long they work (called short- and
long-acting drugs) or the way in which they widen or dilate the airways
beta-agonists, anticholinergics or theophyllines).
5. While all bronchodilators widen the airways, they work in different ways to
do so.
6. It is therefore possible to combine bronchodilators in order to achieve
maximal benefit.


SLIDE 17 Adrenergic Bronchodilators
1. The most effective bronchodilators
2. Mechanism of action (MOA):
• Alpha receptor stimulation which causes vasoconstriction and
vasopressor effect
• Beta-1 receptor stimulation causes increases heart rate (HR) and
myocardial contractility
• β2-adrenergic receptor stimulate adenyl cyclase and increasing
cyclic adenosine monophosphate (cAMP) in smooth muscle cells
bronchodilatation (muscle relax)
3. Almost given exclusively by inhalation:
• Decreases the systemic dose and adverse effects
• Occasionally by nebuliser
4. Aerosol administration:
• Enhances bronchoselectivity
• Provides a more rapid response
• Greater protection againts provocations that induce bronchospasm
(e.g. exercise, allergen challenges) than does systemic administration

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SLIDE 18 Adrenergic Bronchodilators : SABA
Salbutamol
1. Salbutamol was the first selective β2-receptor agonist to be marketed in 1968.
2. It was first sold by Allen & Hanburys under the brand name Ventolin.
3. The drug was an instant success, and has been used for the treatment of asthma
ever since.
Example:
1. Neb 0.5%/10mls: 2ml up to 4 times daily (over a period of 3 mins)
2. Injection 0.5mg/ml
• S/C or IM 500mcg 4 hourly
• Slow IV 250mcg
• IV infusion, initially 5mcg/min
• adjusted according to response and HR, usually in the range 3 - 20mcg/min
3. Metered dose inhaler (MDI) 100mcg/puff: 2 puffs PRN
4. Dry powder inhaler (DPI) 200mcg/puff: 1 - 2 puff PRN
5. Tab 2 mg
• 2 - 6 yrs: 1 - 2 mg TDS – QID
• 6 - 12 yrs: 2mg TDS – QID
• >12 yrs: 2 - 4mg TDS - QID
6. Syrup 2mg/5ml
• 2 - 6 yrs: 1 - 2 mg TDS – QID
• 6 - 12 yrs: 2mg TDS – QID

Salbutamol
1. As a β2-agonist, salbutamol also finds use in obstetrics.
2. Intravenous (IV) salbutamol can be used to relax the uterine smooth muscle to delay
premature labor (5mg/5ml).
3. It’s role has largely been replaced by the calcium-channel blocker (nifedipine), which
is more effective, better tolerated and orally administered.
4. Diet and body building use:
• Salbutamol is taken by some people as an alternative to clenbuterol for purposes
of fat burning and/or as a performance enhancer.
5. Detection of use
• Salbutamol may be quantified in blood or plasma to confirm a diagnosis of
poisoning in hospitalised patients or to aid in a forensic investigation.
• Urinary salbutamol concentrations are frequently measured in competitive
sports programs, for which a level in excess of 1000μg/L is considered to
represent abuse.
• The window of detection for urine testing is on the order of just 24 hours, given
the relatively short elimination half-life of the drug.
6. Doping
• Clinical studies show no compelling evidence that salbutamol and other β2-
agonists can increase performance in healthy athletes.
• In spite of this, salbutamol required “a declaration of use in accordance with the
International Standard for Therapeutic Use Exemptions” under the 2010 WADA
prohibited list.
• This requirement was relaxed when the 2011 list was published to permit the
use of “salbutamol (maximum 1600 micrograms over 24 hours) and salmeterol
when taken by inhalation in accordance with the manufacturers’ recommended
therapeutic regimen“.
• According to two small and limited studies, performed on eight and 16 subjects,
respectively, salbutamol increases the performance even for a person without
asthma.
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SLIDE 19 Salmeterol

DPI 50mcg/puff : 1 puff BD


• Seretide accuhaler (50/250mcg)/puff
• Seretide accuhaler (50/500mcg)/puff
• Weaker than salbutamol but more beta 2 selective
• Duration of action: 3 – 12 hours
• Usually combined with steroids

Formeterol
• DPI 4.5 mcg / puff: 1 - 4 puffs BD (max: 8 puffs /day)
• Symbicort turbuhaler (160/4.5 mcg)/puff
• Last for 12 hours

Toxicity
• Skeletal muscle tremor
• Significant β1 effects (tachycardia) at high clinical dosage
• Arrhythmias may occur when used excessively
• Tolerance, tachyphylaxis (loss of responsiveness) is an unwanted effect

Adverse effects
1. Common side effects :
• Tremor (20%), nervousness (15% in 2 - 6 years old), insomnia (11% in
6 - 12 years old receiving 4 - 12mg BD, headache (4 - 7%), palpitations
and tachycardia

2. Specific side effects:


• Dizziness (1 - 7%), nausea (10%), hypokalemia, loss of bronchoprotection,
hyperglycemia, worsening ventilation perfusion ratio
• CFC induced bronchospasm is managed by replacing HFA propellants


SLIDE 20 Assessment Of Bronchodilator Therapy
1. General assessment:
• Monitoring vital signs (RR, PR, breath sounds)
2. Specific :
• Monitor PEFR
• ABG or SpO2 in acute state
• K+ and blood glucose
• If on long term – monitor PFT
• Action plan for asthma patients
• Patient education
• Correct technique of aerosol delivery
• Cleaning of aerosol device

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SLIDE 21 Mechanism of Action
• Competitively blocks / inhibits muscarinic receptors in the airways
(cholinergic induced bronchoconstriction)
• Effective bronchodilators but not as potent as β2-agonist
• Prevents bronchoconstriction mediated by vagal discharge (antagonizing
effects of acetylcholine)

airway relaxation


SLIDE 22 Ipratropium bromide
1. Quaternary antimuscarinic drug
2. Delivered directly to the airways by pressurized aerosol (MDI)
3. Minimally absorbed (systemic effects are small)
4. In excessive dosage, minor atropine-like toxic effects may occur
5. Does not cause tremor or arrhythmias
6. Need to teach clients how to use properly:
• If using ipratropium bromide with a beta-agonist (SABA), use beta-
agonist 5 mins. before ipratropium bromide
• If using ipratropium bromide with an inhaled steroid or cromolyn,
use ipratropium bromide 5 mins. before the steroid or cromolyn -
bronchioles dilate & drugs more effective
7. Example:
• Neb 0.5mg*/2.5mg → 1 - 2 unit doses (1/1 TDS - QID)
• Neb 0.0125% (125mcg/ml) → 100 - 500mcg up to 3X/d
→ adult: up to 4X/d
• MDI (20mcg*/50mcg)/puff → 1 - 2 puff qid (Max: 8 puff/d)
8. Adverse effect
Common
• Cough (5.9%) and dry mouth (2.4% - MDI; 16% -DPI: gargle the mouth)
• Occasional ( ):
• Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%
(nervousness, irritation, palpitation)
Occasional
• Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%
(nervousness, irritation, palpitation)

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SLIDE 23 Methylxanthines
1. Purine derivatives
2. Bronchodilation is the most important therapeutic effect
3. CNS stimulation, cardiac stimulation, vasodilation and slight increase in BP (due to
release of norepinephrine from adrenergic nerves)
4. Found in plants and provide the stimulant effect of 3 common beverages:
• Caffeine (coffee)
• Theophylline (tea)
• Theobromine (cocoa)
5. Ineffective by aerosol
6. Must be taken systematically (orally or IV) (treatment for asthma)
Example:
THEOPHYLLINE and several analogs:
i. Orally active (125mg)
ii. Available as salts and base, poorly water soluble
SLOW-RELEASE (SR) THEOPHYLLINE 250mg:
i. For control of nocturnal asthma
ii. Most important in clinical use
→ AMINOPHYLLINE 25mg/ml:
i. a low therapeutic index & range (monitor levels frequently – TDM)
ii. Water soluble

Clearance varies
1. Highest in young adolescents
2. Higher in smokers
3. Concurrent use (drug-drug interaction) of other drugs that inhibit or induce hepatic
enzyme (eliminated by cytochrome P450-drug metabolizing enzyme in the liver):
• Reductions in clearance (half life & effects of theophylline): cimetidine,
erythromycin, claritromycin, allopurinol, propanolol, ciprofloxacin, ticlopidine
ects
• Enhance in clearance (effects of theophylline): rifampin, carbamazepine,
phenytoin, phenobarbital, charcoal-broiled meat & cigarette smoking
a. Theophylline and beta-adrenergic agonist given together - synergistic
effect can occur→cardiac dysrhythmias.
b. Due to large interpatient variability in theophylline clearance, routine
monitoring of serum theophylline concentrations (TDM) is esssential for
safe and effective use.
c. A steady-state range: 5 – 15mcg/ml (most patients).
d. Common adverse effects:
• GI distress (it may promote acid reflux, also known as GERD, by relaxing the
lower esophageal sphincter muscle)
• Tremor
• Insomnia

4. Others:
• Anorexia, nervousness, dizzines, palpitations, restlessness, flushing
5. Overdosage
• Severe nausea and vomiting
• Hypotension
• Cardiac tachyarrhythmias
• Convulsion/seizures
C/I: severe cardiac dysrhythmias, hyperthyroidism, peptic ulcer disease (increases
gastric secretions)
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SLIDE 24 Handling Of Inhaler Devices
Metered Dose Inhaler (MDI)

STEP 1:
Remove the mouthpiece cover.

STEP 2:
Hold the inhaler in an upright position as shown in
diagram.

STEP 3:
Shake the MDI 3 - 5 times in an
up -down motion before each
puff to mix the contents of the
canister.

STEP 4:
Exhale slowly and completely through your mouth
before holding your breath.
DO NOT exhales into the mouthpiece.

STEP 5:
• Device should be held at an upright position.
• Insert into mouth with the head slightly tilted.
• DO NOT bites the mouthpiece.

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SLIDE 24
cont
Handling Of Inhaler Devices
Metered Dose Inhaler (MDI)

2 STEP 6:
Begin inhaling slowly through the mouth (1)
and simultaneously actuate the MDI ONCE (2).
3 1
Continue inhalation for about 3-5 seconds until
the lungs are full (3).

STEP 7:
Hold breath for 4 -10 seconds and leave the inhaler
in the mouth while holding breath.

1
STEP 8:
Remove inhaler (1) from mouth and exhale slowly
2
(2).

STEP 9:
Wait 30 seconds to 1 minute before repeating step
3 - 8 if subsequent doses are required.

STEP 10:
Close cap and keep the inhaler in a dry place.

NOTE:
• Patients should be advised to gargle with water after using certain types of MDIs e.g. Inhaled
Corticosteroids (ICS).
• If on two types of inhalers (steroid & bronchodilator), it is recommended to use the bronchodilator
first and wait for 5 minutes before using the steroid.
MAINTENANCE:
• Clean the plastic mouthpiece only, not the metal canister.
• Clean it with tap water at least once a week.

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SLIDE 25 Spacer
I. BI – tube

STEP 1: STEP 6:

Remove the Hold breath for 5-10


mouthpiece cover seconds.
from the metered
dose inhaler (MDI).

STEP 7:
STEP 2:
Wait 30 seconds to 1
Attach the large end minute before repeating
of the BI tube to the step 3 - 6 if subsequent
mouthpiece of the doses are required.
MDI.

STEP 8:
STEP 3:
After use, remove the
Shake the MDI 5 times BI Tube and replace the
in an up -down motion mouthpiece cover on the
(as shown in diagram) MDI.
before use.

STEP 4:
• Exhale slowly and
completely through
the mouth before
holding the breath.
• DO NOT exhales
into the BI tube.

STEP 5:
Press the base of the
canister (1) and inhale
the nebulizer aerosol
(2).

MAINTENANCE:
• Wash the BI tube at least ONCE A MONTH with tap water and air dry.
• Do not wipe the BI tube dry after washing.

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SLIDE 25
cont II. Chamber With Mask

STEP 1: STEP 5:
Visually check for Apply mask to face
foreign objects before and ensure that there
each use. is a good seal.

STEP 6:
STEP 2:
• Press MDI ONCE at
Remove the
beginning of normal
mouthpiece cover
breath.
from the MDI.
• Breathe normally
between 5 - 10
breaths while
holding the mask
firmly to your face.

STEP 3: STEP 7:
Insert the MDI into Slow down inhalation
the adaptor of the if the WHISTLE sound
chamber. is heard.

STEP 4: STEP 8:
While holding the Wait 30 seconds
chamber with MDI to 1 minute before
firmly, shake the MDI repeating step 4 - 6 if
for 5 times in an up- subsequent doses are
down motion (as in required.
diagram).

MAINTENANCE:
• It is recommended to clean ONCE A WEEK.
• Cleaning of the product varies between the different variants of the AeroChamber®. Please refer
to each individual product information

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SLIDE 25
cont III. Chamber With Mouthpiece

STEP 1: STEP 4:

Visually check for Put the mouthpiece in the


foreign objects before mouth.
each use.


STEP 5:
STEP 2:
• Simultaneously press
Remove the cap the MDI ONCE (1) at
from the MDI and the the beginning of a slow
mouthpiece cover of and deep inhalation
the chamber. (2).
• Hold breath as long as
possible, between to
4-10 seconds before
breathing out through
the nose.

STEP 6:
Slow down inhalation if a
WHISTLE sound is heard.
STEP 3:
2 • Insert the MDI into
the adaptor of the
mouthpiece (1).
• While holding the STEP 7:
1 mouthpiece with
Wait 30 seconds to 1
• MDI firmly, shake minute before repeating
the unit for 5 times step 3 - 6 if subsequent
in an up-down doses are required.
motion as shown in
diagram (2).

MAINTENANCE:
• It is recommended to clean ONCE A WEEK.
• Cleaning of the product varies between the different variants of the AeroChamber®. Please refer to
each individual product information leaflet.

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SLIDE 25 Acuhaler
cont The dose counter read 60, indicating the full number of doses.

STEP 1: STEP 4:
• Hold the outer case • Put the mouthpiece
in one hand and into the mouth and
put the thumb of ensure a good seal.
the other hand on
• Breathe in forcefully
the thumb grip to
and deeply through
open the Seretide®
the mouth only.
Accuhaler®.
• Push the thumb
grip as far as it will STEP 5:
go until a “CLICK”
Remove the
sound is heard.
Accuhaler® from
the mouth and hold
STEP 2: breath for 10 seconds
or as long as possible.
• Hold the device
horizontally with
the mouthpiece
towards the
patient. STEP 6:
• Slide the lever as • Close the device by
far as it will go as sliding the thumb
in diagram until grip back to its
another “CLICK” original position
sound is heard to until a “CLICK”
load a dose in the sound is heard.
device.
• The lever will
return to its original
position and will be
STEP 3:
reset.
• Hold the Accuhaler®
away from mouth
and breathe out STEP 7:
completely.
• Repeat step 1 - 6 if
more than one dose
is required.

• Close cap and keep
the inhaler in a dry
place.

NOTE:
• Patients should be advised to gargle with water after using the Seretide®Accuhaler®.
• Number 5 to 1 appear RED to warn that there are only a few doses left.

MAINTENANCE:
• Wipe the mouthpiece of the Seretide® Accuhaler® with a dry cloth or tissue to clean it.
• The Accuhaler® is recommended to be cleaned at least ONCE A WEEK.
• The content of the device is susceptible to moisture. For this reason keep it in a dry place away
from humidity.

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SLIDE 26 Turbuhaler
A. Preparing a new Turbuhaler (Priming)

STEP 1:
Unscrew and lift off the cover.

STEP 2:
• Hold the Turbuhaler® upright with the grip facing
downwards.
• Turn the grip as far as it will go (1) and then turn it
1
back as far as it will go in the opposite direction (2)
until a “CLICK” sound is heard.
• Perform this procedure TWICE.

B. Used Turbuhaler
STEP 1:
Unscrew and lift off the cover.

STEP 2:
• Hold the Turbuhaler® upright with the grip facing
downwards.
• DO NOT holds the mouthpiece when turning the
grip.

STEP 3:
To load the Turbuhaler® with a dose, turn the grip
as far as it will go in one direction as shown in the
diagram.

STEP 4:
Then turn it back again as far as it will go in the
opposite direction until a “CLICK” sound is heard.

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SLIDE 26 B. Used Turbuhaler cont
cont
STEP 5:
Breathe out away from the mouthpiece.

STEP 6:
• Place the mouthpiece gently between the lips.
• Ensure a tight seal around it as in diagram.

STEP 7:
Breathe in forcefully and deeply through the mouth
only.

STEP 8:
• Remove the Turbuhaler® from the mouth before
breathing out again.
• DO NOT breathes into the mouthpiece.

2
8
3
STEP 9:
7 Repeat step 2 - 8 if more than one dose is required.
4

6 5

STEP 10:
Replace the cover and store Turbuhaler® in a dry
place.

NOTE:
• Patients should be advised to gargle with water after using steroid containing Turbuhalers®.
• If on two types of Turbuhalers® (steroid & bronchodilator), it is recommended to use the
bronchodilator first and wait for 5 minutes before using the steroid.
2
• Turbuhaler® has a dose indicator that shows how many doses are left in the inhaler. It moves
slowly when each time a dose is loaded. When the red colour first appears in dose indicator, it
6
shows that there are only320 doses left.
MAINTENANCE:
• Clean the outside of the mouthpiece once a week with a dry cloth or tissue.
• Never use
5 water or any other
4 fluid when cleaning the mouthpiece.
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SLIDE 27 Easyhaler
a. Preparing the powder inhaler for first use

STEP 1:
Remove the powder inhaler from the laminated
pouch.

Protective cover
STEP 2:
• Insert the powder inhaler into the
protective cover.
• The dust cap on the mouth piece prevents
Dust Cap
accidental actuation of the inhaler when
inserting it into the protective cover.

b. Delivering the medication

STEP 1:
Remove the dust cap.

STEP 2:
• Shake the device prior to each dose.
• After shaking, hold the device in the upright
position.

“CLICK”
STEP 3:
• Press the device only ONCE between the
thumb and forefinger until a “CLICK” sound
is heard.
• Keep holding the device in the upright
position.

STEP 4:
Breathe out normally, away from the
mouthpiece.

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SLIDE 8
2

27 cont STEP 5:
3

7 • Place the mouthpiece between lips and


4 close tightly around the mouthpiece.
6 5 • Breathe in forcefully and deeply through
the mouth only.

STEP 6:
Remove the inhaler from mouth and hold breath
for 5 - 10 seconds.

2
STEP 7:
6 3
Repeat step 2 - 6 if more than one dose is
required.

5 4

STEP 8:
• Put the dust cap back on the mouthpiece.
• Store Easyhaler® in a dry place.

NOTE:
• Patients should be advised to gargle with water after using steroid containing
Easyhalers®.
• If on two types of Easyhalers® (steroid & bronchodilator), it is recommended to use
the bronchodilator first and wait for 5 minutes before using the steroid.
• Easyhaler® has a dose counter which indicates the number of remaining doses. The
counter turns after every five actuations. When the counter turns red there are 20
doses left.

MAINTENANCE:
• The mouthpiece can be cleaned with a dry cloth or tissue. Never use water or any
other fluid when cleaning the mouthpiece.
• Inhalation powder should not be exposed to humidity. If the powder becomes damp,
it is not suitable for use and should be disposed of.

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TOPIC 6

APPLICATION OF
PEAK FLOW METER
AND SPIROMETRY
IN MANAGEMENT
OF ASTHMA

Training Module For


Health Care Providers

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TOPIC 6: APPLICATION OF PEAK FLOW METER AND
SPIROMETRY IN MANAGEMENT OF ASTHMA
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Learning Objective
• Spirometry and peak flow meter are the most important tools in monitoring the control level of the
asthmatic.
• Peak flow meter is the common instrument that is use at the primary care setting.
• Able to use peakflow meter and analyze the reading
• Spirometry reading scale is more accurate compare to peak flow meter in diagnosing a patient lung
capacity. The pro and cons of the instrument is mentioned at the end of the topic.

APPLICATION OF PEAK FLOW METER AND SPIROMETRY IN MANAGEMENT


OF ASTHMA

SLIDE 1 Peak Expiratory Flow Rate

Person ‘s maximum speed of expiration, as measured with a peak flow meter

SLIDE 2 Peak Flow as Diagnostic Tool


1. Less accurate than diagnostic instruments
2. Cannot be calibrated or checked to assure their performance
3. No graphical display to evaluate effort, quality
4. Current PEF standards of ± percent allow models of instruments to vary by
up to 20 %

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When is peak flow useful ?
1. Diagnosis occupational asthma
2. Help in diagnosis when spirometry in not available
3. Evaluate response
4. Early detection of worsening asthma


Diurnal variability of peak expiratory low rate (PEFR) greater than 20% for at
least three days in a week for two weeks is typical of asthma

Or improvements in PEF
1. 10 minutes after high dose bronchodilator through a spacer (60 liters
change)
2. After six weeks courses of inhaled steroids
3. After 14 days of 30 mg prednisolone
4. Assessment of the response to treatment

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SLIDE 5 Peak Flow Monitoring

Long term daily PF monitoring can be helful to:


1. Detect early changes in asthma control that require adjustments in
treatment
2. Evaluate responses to changes in treatment
3. Provide a quantitative of impairment


SLIDE 6 As part of asthma action plan
1. Provide to all patients a written AAP based on signs and symptoms and /
or PEF
• Written AAP are particularly recommended for patients who have
moderate or severe persistent asthma, a history of severe excerbations
or poorly controlled asthma
2. Whether PF monitoring, symptom monitoring (available data show similar
benefits for each) or a combo of approaches is use, self monitoring is
important to the effective self management of asthma.


SLIDE 7 Do I need spirometry to make the diagnosis of asthma – YES
• History and physical are not reliable means of excluding other diagnoses,
or of characterising the status of lung impairment
• Pulmonary function reports do not reliably correlate with symptoms, and
the two together are needed for disease classification
• Peak flows are considered too variable to be accurate for diagnosis. They
are more appropriately used for disease monitoring
• Children over 5 are usually able to participate
NAEPP guideline section 3. 2007

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SLIDE 8 What is spirometry
• Spirometry is a pulmonary function test that measures the volume of air
an individual inhales or exhales as a function of time
• Spirometry measures how much and how quickly air can be expelled
following a deep breath
• Flow or the rate at which volume is changing as a function of time can also
be measured with spirometry
• A powerful tool that can be used to assess , follow and manage patients
with asthma
• Is much more reliable and relatively simple to incorporate into a routine
office visit
• Spirometry provides an objective measure of airflow obstruction
• Spirometry is necessary for diagnosis, peak flow is used for monitoring
control
• Is an effort – dependent manoeuvre that requires understanding,
coordination and cooperation by the patient
• It is all about the technique
• Recommendation is to obtain a sufficient number of manoeuvers of
adequate quality
• Are they acceptable and reproducible, implying that the maximal effort
has been achieved


SLIDE 9 Spirometry: Suitable for resource limited facility
1. Inexpensive and user friendly, spirometers are now readily available for
office use
2. Much more reliable and relatively simple to incorporate into a routine
office visit
3. Modern office spirometers are portable, process numeric results
automatically and print out pre and post report
4. Accurate results accurate equipment


SLIDE 10 Importance of spirometry
1. Provides objective measure of lung function
2. Establishes airflow obstruction and REVERSIBILITY!
3. Assists in asthma diagnosis and treatment
4. Assists in determining asthma severity and asthma control

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SLIDE 11 Spirometry components
1. Forced Vital Capacity (FVC) - the maximal volume of air forcibly exhaled
from the point of maximal inhalation
2. Forced Expiratory volume in 1 second (FEV1) - the volume of air exhaled
during the first second of the FVC
3. FEV1/FVC - ratio of FEV1 to FVC, expressed as a percentage
4. Peak Expiratory Flow Rate (PEFR) is the maximum air flow (rate)during
forced exhalation


SLIDE 12 Objective measurement
• Abnormalities of lung function are categorised as obstructive or restrictive
defects
• A reduced ratio of FEV1 / FVC as compared to the predicted value, indicates
obstruction to the flow of air to the lungs
• A reduced FVC with a normal FEV1 / FVC ratio suggest a restrictvie pattern


SLIDE 13 Spirometry results
• Airflow obstruction is indicated by reduced FEV1 and FEV1 / FVC values
relative to reference or predicted value
• The predicted depend on the individual’s age gender, height and race
• The numbers are presented as percentages of the average expected
in someone of the same age, height, sex and race. This is called percent
predicted.


SLIDE 14 Interpreting spirometry
• Normal values for FEV1 and FVC are expressed in both absolute numbers
and percent predicted of normal
• Values for FVC and FEV1 that are above 80% of predicted are defined as
within the normal range
• FEV1 / FVC ration declines as a normal part of ageing

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SLIDE 15 Is airflow obstruction present and is it at least partially reversible?
Use spirometry to establish airflow obstruction
• FEV1 < 80 % predicted
• A reduced ration of FEV1 / FVC as compared to the predicted value,
indicates obstruction to the flow of air to the lungs

Use spirometry to establish reversibility


• FEV1 increases ≥ 12 % and at least 200 ml after using a short acting inhaled
Beta 2 – agonist
• A 2 to 3 weeks trial of oral corticosteroid therapy may be required to
demnonstrate reversibility

Image 1: Volume time curve Image 2: Flow volume loop


SLIDE 16 • Obstructive lung disease changes the appearance of the flow volume
curve
• As with a normal curve there is a rapid peak expiratory flow, but the curve
descends more quickly than normal and takes on a concave shape

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SLIDE 17 Restrictive Flow Volume Loop

The shape of the flow volume loop is relatively unaffected in restrictive disease,
but the overall size of the curve will appear smaller when compared to normals
on the same scale.


SLIDE 18 Reliability of spirometry
1. Correct technique, caliberation methods and maintenance of equipmemy
are necessary to achieve consistently accurate test results
2. Calibration must be performed daily
3. Maximal patient effort in performing the test is required to avoid important
error in diagnosis and management (reproducibility)
4. Spirometry is an effort – depedent manoeuvre that requires understanding,
coordination and cooperation by the patient – subject who must be
carefully instructed
5. Technicians must be trained and must maintain a high level of proficiency
to assure optimal results
6. Spirometry should be performed using equipment and techniques that
meet standards developed by the American Thoracic Society

Criteria for acceptibility include


7. Lack of artefact induced by coughing, glottic closure or equipment problems
(primarily leak)
8. Satisfactory start to the test without hesitation
9. Satisfactory exhalation with six seconds of smooth continuous exhalation
or a reasonable duration of exhalation with a plateau
10. Poor effort can be detected if the patient does not blow long enough
(6 seconds) or hard enough (classic shape)
11. Maximal patient effort in performing the test is required to avoid important
errors in diagnosis and management
12. Spirometry is generally valuable in children over age 4, however, some
children cannot conduct the manoeuvre adequately until after age 7

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SLIDE 19 Spirometry recommendations
• At the time of initial assessment
• After treatment is initiated and symptoms and peak flow have stabilised
• During periods of loss of asthma control
• When acessing a response to a change in pharmacotherapy
• At least every 1 to 2 years to assess the maintenance of airway function

NAEPP guidelines


SLIDE 20 Spirometry may be done more frequently
Depending on clinical severity, spirometry is also useful
• As a periodic check on the accuracy of the peak flow meter
• When more precision is desired to evaluate response to therapy
• When peak flow results are unreliable


SLIDE 21 As part of asthma action plan (AAP)
• Provide to all patients a written AAP based on signs and symtoms and / or
PEF
– Written AAPs are particularly recommended for patients who
have moderate or severe persistent asthma, a history of severe
exacerbations or poorly controlled asthma
• Whether PF monitoring, symptoms monitoring (available data show similar
benefits for each), or a combo of approaches is used, self monitoring is
important to the effective self management of asthma.


SLIDE 22 Conclusion
• Both spirometry and peak flow play important role in the management of
asthma
• Spirometry would be able to diagnose asthma objectively
• Objective monitoring can be achieve by using peak flow especially in
moderate to severe asthma

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TOPIC 7

HOW TO INTERPRET
SPIROMETRY
RESULT

Training Module For


Health Care Providers

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TOPIC 7: HOW TO INTERPRET SPIROMETRY RESULT
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Learning objective
• Peak expiratory flow rate and spirometry are important in assessing the level of asthma diagnosis
and management. Therefore the interpretation of the results must be accurate. There are a few of
Spirometry graph shown in this topic for discussion

HOW TO INTERPRET SPIROMETRY RESULT

SLIDE 1 Outline
1. ATS guidelines
2. Clinical data review
3. Volume-time curve
4. Flow-volume curve
5. Spirometry
6. Reaching a conclusion
7. Cases

ATS Guideline
SLIDE 2
Within manoeuvre criteria
I. Individual spirograms are “ acceptable “ if
a. They are free from artefacts:
• Cough during the first second of exhalation
• Glottis closure that influences the measurement
• Early termination or cut off
• Effort that is not maximal throughout
• Leak
• Obstructed mouth piece
b. They have a good starts
• Extrapolated volume < 5% of FVC or 0.15 litres whichever is greater
c. They show satisfactory exhalation
• Duration of ≥ 6 seconds (3 seconds for children) or a plateau in the
volume time curve or if the subject cannot or should not continue to
exhale
II. Between manoeuvre criteria
a. After three acceptable spirograms have been obtained, apply the
following tests:
• The two targets values of FVC must be within 0.150 L of each other
• The two largest values of FEV1 must be within 0.150 L of each other
b. If both of these criteria are met, the test session may be concluded
c. If both of these criteria are not met, continue testing until
• Both of the criteria are met with analysis of additional acceptable
spirograms or
• A total of eight tests have been performed (optional) or
• The patient / subject cannot or should not continue
d. Save as a minimum, the three satisfactory manoeuvres.
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Clinical data review
1. Clinical history
2. Patient demography
3. Technician’s comments

Volume time curve

Figure 1: Volume time curve


SLIDE 4 Components of the curve
• FVC: height of the curve (Figure 2)
• FEV1: volume corresponding to 1 sec (Figure 3)
• FEF25,50,75,25-75: extracted from curve’s (Figure 4)

Slope

Figure 2 Figure 3

Figure 4

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SLIDE 5 Good curve quality
• Good start
• Smooth curve, free from artefact
• Good end


SLIDE 6 Examine the components of the curve
• Height (PEF) and slope (FEF25-75): low – suggestive of obstructive
disorder
• Width (FVC): smaller than predicted curve, suggest restrictive (mainly) or
obstructive (less)
• 1st second mark (FEV1): estimate FEV1/FVC – low suggest obstructive


SLIDE 7 Examine the post bronchodilator curve
1. Examine the size, shape and location, compared to pre - bronchodilator
2. If the is improvement, it might indicate response to bronchodilator

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SLIDE 8 Examine FEV1, FVC and FEV1/FVC ratio

FEV1 FVC FEV1 / FVC


Normal Normal Normal Normal
Obstructive Reduce Normal Reduce < 0.7
Restrictive Normal or reduce Reduce Normal or increase
Mixed Reduce Reduce Reduce

Examine the post bronchodilator value of FEV1, FVC and FEV1/FVC


Significant response: 12% and 200ml in FEV1 or FVC


SLIDE 9 Examine FEF25,50, 75, 25-75
1. If low may suggest obstruction
2. May also be low in restrictive disorder and upper airway obstruction

Look at the rest of the results


3. PEF may decrease in:
• Poor effort
• Obstruction
• NMD
4. FET: Appropriate exhalation 6 sec
5. Excessively prolonged suggest mild obstruction


SLIDE 10 Special situations
• Isolated low MMEF OR FEF indicates airflow limitation at low lung volume
• Isolated significant response to bronchodilator with normal baseline
suggest asthma


SLIDE 11 Reaching A Conclusion’
Obstructive disorder:
1. You will need then to differentiate between the two major
2. Obstructive disorders – asthma and emphysema:
• FV curve: a “dog-leg” appearance is characteristic for emphysema.
• Spirometry: a significant bronchodilator response is suggestive of
asthma.
3. Remember that other obstructive disorders (such as bronchiectasis,
obstructive bronchiolitis, and chronic bronchitis) could be responsible.

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SLIDE 12 Restrictive disorder.
The two major groups of disorder involved are as follows:
1. Parenchymal restriction, like ILD
2. Chest wall restriction (NMD, MSD, diaphragmatic paralysis and morbid
obesity)


SLIDE 13 The following helps for the distinction
FV curve:
1. A small curve with a steep slope suggests a parenchymal restriction.
2. A small curve with a parallel slope to the unpredicted curve suggests a
chest wall restriction other than NMD.
3. A convex curve suggests NMD or poor effort study.

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CHAPTER 2

QAP ASTHMA
“APPROPRIATE
MANAGEMENT
OF ASTHMA”

Training Module For


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CHAPTER 2: QAP ASTHMA
“APPROPRIATE MANAGEMENT OF ASTHMA”
TRAINING MODULE FOR HEALTH CARE PROVIDERS

QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”

What Is Quality Assurance?

Quality Assurance (QA)


• Is a process-centered approach to ensuring that a company or organization is
providing the best possible products or services.
SLIDE 1 • It is related to quality control, which focuses on the end result, such as testing
a sample of items from a batch after production.
• Although these terms are sometimes used interchangeably, quality assurance
focuses on enhancing and improving the process that is used to create the end
result, rather than focusing on the result itself.
• Among the parts of the process that are considered in QA are planning, design,
development, production and service

SLIDE 2 QAP Indicator in Bahagian Pembangunan Kesihatan Keluarga


1. Maternal & Child Health
• Incidence rate of severe neonatal jaundice (NNJ)(Std:100 /10000)
• Visual defect detection rate among standard one school children (Std:
>5%)
2. Primary Care
a. Disease Base
• Appropriate Management of Patient with Asthma (Beating own
standard)
b. System Base
• Client Friendly Clinic (Beating own standard)
3. Clinical Support
• Film rejection rate (<2.5%)
• Lab-Total Turn Around Time (L-TTAT)(>95% less than 30 minutes)
• Proportion of wrongly filled prescription detected before dispensing (0)

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SLIDE 3 QAP Indicator
Appropriate Management of Asthma

Quality Assurance Process


1. Involve all health clinics with Medical Officer
2. Start off with:
• Development of baseline
• Remedial measures
• Periodic continuous evaluation
3. Remedial measures include
• Training and retraining of PHC personnel
• Supply of appropriate and adequate equipments
4. Evaluation process
• Based on an benchmarking approach, done annually so that continuous
improvement based on recommendation can be accomplished.


SLIDE 4 QAP Indicator - Appropriate Management of Asthma
1. Indicator
• % of Asthmatic cases that received appropriate treatment of Asthma
(6/6)
2. Purpose of indicator
• Monitor appropriateness of Asthma treatment by PHC personnel
Resulting quality performance hence reduce number of asthmatic
attack and morbidity
3. Advantages of indicator
• Status of Asthma treatment
• Present Asthma treatment is adequate and effective
• Indicates areas to be strengthen for Asthma treatment
• Ensure use of CPG on Asthma treatment


SLIDE 5 QAP Indicator - Appropriate Management of Asthma

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SLIDE 6 QAP Indicator - Appropriate Management of Asthma
Outcome
1. Medical outcome
• Improve compliance
• Reduce attacks and complications
2. Service Outcome
• Improve quality management by Medical Assistant and Doctor
3. Cost Outcomes
• Reduce severe morbidity and its costs


SLIDE 7 Definitions
1. Asthma
• Condition characterised by airway inflammation due to airway hyper
responsiveness, presenting with episodic or chronic wheeze and/or
cough
2. Asthmatic case
• Patient being diagnosed to suffer from BA by MO / trained personnel.
The diagnosis should be reviewed & confirmed by FMS / M&HO once
before inclusion into the study to ensure correct diagnosis
3. App. treatment of asthma
• Accepted if the asthmatic case of the HC received care as being
recommended or following the MOGC for treatment of asthma


SLIDE 8 Criteria for Appropriate treatment of Asthma
1. On recommended drugs i.e inhalers
2. PHC personnel using the app. monitoring tools i.e ACT & Levels of Asthma
Control (GINA)
3. Client well informed:
• About symptom of asthmatic attack and has his / her plan of action
• When and where to seek medications
4. Client knows:
• When to use inhalers
• How to use inhaler correctly

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SLIDE 9 Materials required for App. treatment of Asthma
1. Inhalers
2. Asthma register
3. Nebulizer
4. PFM
5. Oxygen cylinder
6. Inhalers
7. Sx record chart
8. Other medications
9. CPG
10. Patient education material


SLIDE 10 Methodology (Baseline And Annual Evaluation)
1. Type of study
• Cross sectional analysis of the management of patients with Asthma
2. Sampling frame
• All asthmatic patients on follow up
3. Sample size
• 10 or 30% (not > 100)
4. Sampling method
• Random sampling from Asthma patient’s register
5. Exclusion criteria
• Mild asthmatic, Severely ill, In emergency, Children (<12 yrs)
• Communication problem


SLIDE 11 Methodology (Baseline And Annual Evaluation)

Data collection
1. Interview
a.
Trained paramedic (preferably from other clinic)
b.
Using questionnaires
c.
Time of interview

• Any clinic day at any time of the day.

• Take a few days to weeks, depending on how soon the expected
number of samples is reached.
• Periods to be avoided
- Rainy seasons
- School holidays
- Post-public holidays
2. Patient’s record

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SLIDE 12 Methodology (Baseline And Annual Evaluation)
I Method of Analysis
• Completed questionnaire collected and analysed by M&HO
• The total score of performance is 6
• The Analysis will be based on the percentage of the total marks

Calculation of heatlh clinic performance


Number of respondents achieved 6/6
X 100 %
Total number of respondents

II Limitations of Indicator
• Asthma control is highly dependent on patient’s compliance

III Performance Analysis


a. Clinic level
• Score Distribution Chart
- Main tool to show the level of appropriateness
- Plotted following the year to show the trend
b. District level
• Score Distribution Chart
- Plotted to compare performance among health clinics in the district
for the specified year.

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SLIDE 13 QAP Indicator Appropriate Management of Asthma

Methodology (Baseline And Annual Evaluation)

Performance Analysis
• Main monitoring tool at the district, state and national level is the Indicator
Chart
- Drawn up by year to compare the present performance with the
previous year(s).
• Trend of median ‘percentage of appropriate management of Asthma in the
health clinics’ is the main concern.


SLIDE 14 QAP Indicator Appropriate Management of Asthma
Quality status
The status of quality for clinic/district/state in a specific year is determined by
comparing the percentage of respondent who gets 6/6 with the median value
of previous year


SLIDE 15 QAP Indicator Appropriate Management of Asthma
Remedial Measures
Using the evaluation, strengths and weaknesses identified to facilitate drawing
up of remedial interventions activities:
• Training on MOGC
• Adequate supply of instruments and drugs

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CHAPTER 3

MANAGEMENT
OF BRONCHIAL
ASTHMA IN HEALTH
CLINIC: OUTCOME &
REMEDIAL MEASURES
CONDUCTED AT
HEALTH CLINIC TAMPIN
SINCE 2008

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TOPIC: MANAGEMENT OF BRONCHIAL ASTHMA IN HEALTH
CLINIC: OUTCOME & REMEDIAL MEASURES CONDUCTED AT
KK TAMPIN SINCE 2008
TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF BRONCHIAL ASTHMA IN HEALTH CLINIC: OUTCOME &


REMEDIAL MEASURES CONDUCTED AT KK TAMPIN SINCE 2008

SLIDE 1 Background
• FMS in Tampin Health Clinic involved in development of national asthma QA
in 2002/2003
• Started to implement in Tampin HC in 2004
• All asthma patient registered in asthma registration book
• 2004: FMS invent initial clerking sheet for asthma
• Using ordinary OPD card
• Medical officers reminded to manage asthma appropriately from time to
time

COUNTER

DOCTOR’S ROOM
IN COMMON POOL

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SLIDE 2 Asthma card documentation : 2003-2008
• Ordinary OPD card (yellow card)
• Guided clerking sheet for first time evaluation
• A 4 size asthma diary
• Registration book


SLIDE 3 Problem identified
• Good progress during initial years but later dropped badly

Year Percentage with full marks (6/6)


2004 45.2%
2005 60%
2006 70%
2007 63.9%
2008 33.1%


SLIDE 4
Problem statement
Inability to sustain good quality of care for patients with asthma in Tampin
Health Clinic


SLIDE 5 Why?

SYSTEM
STAFF PATIENT

INABILITY TO
SUSTAIN
GOOD CARE

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SLIDE 6 Problem : Staff factor
• Changing staff / doctor : FMS need to keep on reminding, supervising &
auditing
• No assistant / sharing assistant in most common room
• Too varieties of patients : staff difficult to focus
• Sharing peak flow meter : many patients not assess
• Difficult to practice according to recommendation : staff forgotten easily
• Want to clear patients crowd fast : cont same….
• New staff: Misinterpret / wrong data entry


SLIDE 7 Problem: System factor
• Not staff friendly
• Difficult to sustain performance
• Too dependent on trained staff
• “ Pahat & penukul “


SLIDE 8 Problem: Patient factor
• Just want to come to clinic during asthmatic attack : most of the patient
come at night
• Forgotten to chart or bring to clinic / lost the given asthma diary
• Want quick fix : short acting oral bronchodilator still preferred, not comply
to steroid MDI


SLIDE 9 Intervention: Staff
• Education about asthma
• Regular supervision by FMS
• Provide tool to make them remember easily; quick guide at outer inner
of patient’s folder, guided clerking sheet in line with requirements for
appropriate management of asthma
• Designated staff in NCD service to help them more focus ( but they do
cover other sites too: multitask, integrated yet specialized)
• Try to stick to same staff for data entry or to ensure staff trained first
before enter data

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SLIDE 10 Intervention : System
• Appointment system
• Guided clerking sheet that contain 6 key questions in asthma QA
• Special folder
• Patient’s home based card with monthly diary for 1 year
• Patient seen in NCD site : all will be seen by paramedic first then seen by
doctor
• Co morbidity: choice of card: follow sequence of dominance (DM, HPT,MCH)
– guided clerking sheet


SLIDE 11 Intervention: patient
• Appointment system
• Home based card with diary, appointment date and general info about
asthma, asthma action plan

COUNTER

THEN MO


SLIDE 12 6 important questions
1. Client is on the recommended drug
2. Public Health Care personnel is using appropriate monitoring tools,
3. Client is well informed about symptoms of an asthmatic attack,
4. Client is informed when and where to seek medication,
5. Client knows when to use the inhaler, and
6. Clients knows how to use the inhaler correctly.

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SLIDE 13 Outcome: district performance

Clinic 2012
Tampin 93.3%
Gemencheh 87.1%
Jelai 96.7%
Air Kuning 86.7%
Gemas 84.4%
District Median 89.6%


SLIDE 14 Work Process

Duties Responsible staff


Registration
Staff at registration counter
Giving ACT to patient
Checking ACT
JM/SN/AMO at NCD service
Initial assessment
Full assessment MO
Appointment JM


SLIDE 15 Community Nurse / Staff Nurse / Medical Officer NCD Service
• Initial clerking
• Explaining about all elements about asthma based on patient’s booklet
• Assess and examine patient based on asthma initial clerking and checklist
up to inhaler technique*
• Register in asthma registration book
• Giving appointment to patient
* And checking patient has filled up ACT correctly and jot down ACT score

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IMPROVING QA
ASTHMA THROUGH
A DISTRICT
SPECIFIC APPROACH
(DISTRICT OFFICE
KUALA LANGAT)

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IMPROVING QA ASTHMA THROUGH A DISTRICT SPECIFIC
APPROACH (DISTRICT OFFICE KUALA LANGAT)
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Improving QA Asthma through a District Specific Approach

SLIDE 1 MOH QAP Appropriate Management of Asthma 2007- 2009

2007 2008 2009

30.0% 33.3% 23%

Further random audit on asthma cards at 3 clinics in February 2009 showed that
assessment and follow up care of asthmatic patients were not optimum. Patients
either came for exacerbations or just to take inhalers)

SLIDE 2 Literature Review


CPG Management of Adult Asthma 2002

Determination of severity of asthma based on day & night symptoms, limitation


of activities, episodes of reliever, nebuliser use and lung function test finding
(Intermittent or Persistent)

Global Initiative of Asthma (GINA) guideline 2008


Simplified it as controlled, partly controlled or uncontrolled

Characteristic Controlled Partly Controlled Uncontrolled


(All of the (Any measure
following) present in any week)
Daytime None (twice or More than
symptoms less a week) twice / week
Limitations of None Any
activities
Nocturnal None Any
symptoms/
awakening One in any week
Need for reliever/ None (twice or More than twice/
rescue less a week) week
Lung Function Normal < 80% predicted or
(PEF or FEV1) personal best
(if known)
Exacerbations None

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General Objective
To increase the percentage of asthmatics receiving optimal assessment during
follow up in Kuala Langat Health Clinics.

Specific Objectives
1. To identify contributing factors to the low percentage of patients receiving
optimal assessment during follow up
2. To formulate intervention strategies to increase percentage of patients
receiving optimal assessment during follow up
3. To carry out remedial actions towards the objectives efficiently
4. To re-evaluate the effectiveness of remedial actions taken


SLIDE 4 Definition
Optimal assessment
Assessment of patients covering all of the following 6 criterias
1. Daytime symptoms
2. Nocturnal Symptoms
3. Limitation of activity
4. Need for reliever/ rescue
5. Use of nebuliser/ A&E visit
6. PEFR (percentage over predicted or personal best)

To determine the patients’ level of asthma control based on Global Initiatives


For Asthma Guideline (GINA) 2008


SLIDE 5
Indicator & Standard

Indicator Percentage of Asthmatics receiving optimal assessment


during follow up in Kuala Langat Health Clinics.

Formula Number of patients receiving optimal assessment x 100


Total number of asthmatic patients seen
Standard ≥ 80%

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SLIDE 6 Verification study showed
1. Only 2.4 % of patients being assessed optimally
2. The assessment tools were lacking
3. Knowledge of staffs were also lacking

Problem identified Remedial Action


Immediate Long Term
1. Poor Development of Continuous monitoring system
assessment assessment checklist
based on the 6 to aid process by (regular audit of the asthma record
criteria creating ASTHMA book)
RECORD BOOK
replacing the OPD card


SLIDE 7 Problem identified Remedial Action
Immediate Long Term
2. Unestablished Development of Audit on the implementation in
local protocol implementation the clinics and identify problems
on Management protocol on related to it.
of Asthmatic Management of
Asthmatic patients in Periodic review of the local protocol.
patients in the
the clinic
clinic


SLIDE 8 Problem identified Remedial Action
Immediate Long Term
3. Inadequate Phase 1: Provision Regular checking of tools based on
assessment of assessment tools checklist twice a month.
tools in to all consultation,
clinics (Peak screening and
flow meter, treatment rooms.
mouth piece Phase 2:
& Peak flow Development on
normogram) “ASTHMA KIT”


SLIDE 9
Problem identified Remedial Action
Immediate Long Term
1. Inadequate Workshops on Regular assignments for AMO on
educational “Assessment & case studies
activities for Management of
Asthmatic Patients” Mentor – Mentee activities in
Health Care respective clinics
Providers for all health care
providers.

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SLIDE 10 Proses Pengendalian Pesakit Asthma Di Klinik

Patient come
Patient come to to
healt clinic
healt clinic

determine the level


of asthma control

Evaluate again
the asthma


SLIDE 11 DSA QA Indicator

The percentage of patients optimally assessed at 4th cycle: 79 %


Standard ≥ 80%


SLIDE 12 QA Asthma: Any changes?

2007 2008 2009 2010 2011 2012

30 33 23 28 47 70.9


SLIDE 13 Together with the DSA…………Phase II

Improved on inhaler technique of patients


• Improve assessment flow (when to refer to pharmacist)
• Improve the knowledge and skills of HCP on inhaler technique checking
• Create teaching tool – a video on patient demonstrating inhaler technique
to improve skills of HCP.
• The project was extended to the all Selangor in early 2012
1. The Asthma book was revised.
2. The PEFR normogram was made into a poster form.
3. Asthma diary was distributed to all districts

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ELEVATE THE
PERCENTAGE OF
CONTROLLED
BRONCHIAL ASTHMA
AT PENDANG DISTRICT

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ELEVATE THE PERCENTAGE OF CONTROLLED
BRONCHIAL ASTHMA AT PENDANG DISTRICT
TRAINING MODULE FOR HEALTH CARE PROVIDERS

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL


ASTHMA AT PENDANG STRICT

SLIDE 1 General Objective


Increase the controlled percentage of bronchial asthma

MAIN OBJECTIVES:
1. To determine the level of asthma controll in Pendang District
2. To detect the main factor which caused the level of controlled asthma is low.
3. To plan a framework and implement the plan of action in controling the
bronchial asthma level.
4. Research and restudy regarding the plan of action is created for effective
detection and evaluation should be rule out.

SLIDE 2 Indicator Percentage of controlled asthma

Formula:

Total number of controlled bronchial asthma


_______________________________ X 100%
Total brochial asthma patient

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PROCESS OF CARE

Registration

Trace the defaulter


Screening and PERF reading measurement

History taking and physical examination

Accurate diagnosis based on Athma CPG

N= 1246
Severity

Controlled Not controlled


Wheeze with ARI
< 3 years
Treatment and Refer to Physician
counseling (Medical Officer / Family
Medicine Specialist
Persistent
Appointment wheeze
Refer to hospital

Ref: Martinoz FD N
Filling system


SLIDE 4 Model Of Good Care
Process of care Criteria Standard

1. Registration Full patient profile 100%


- Age , gender
- Address
- Phone number

2. History taking History taking based on the criteria in the clinical practice 100%
guideline

3. Managing Managing criteria based on Bronchial Asthma CPG 100%


and effective 1. Client use the inhaler Nil
implementation 2. Health Officer will do record the PEFR reading and
monitor level of asthma control.
3. Client must know the symptom of asthma
4. client is aware of where to get the medication.
5. Client know the right technique of inhaler
6. Client know how to use and when to use the inhaler
7. Uncontrolled case is monitor by the Medical Assistant

4. Defaulter tracing All defaulter cases should be contact within 2 weeks from 100%
the actual appointment date.

5. Health education 1. All health care officer should attend the management 100%
of bronchial asthma course once a year.

2. Need to establish standard module for Inhalation 100%


technique for each patient - handling of inhaler device
a practical guide for pharmacist (MoH)
75%
3. Consultation for new patient is after 3 months
70%
4. Consultation for old patient after a year

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SLIDE 5 Methodology
Sampling metod:
• All sampel taken from asthmatic patient which visited from March 2009
(verification study) and March 2001 (improvement study)
• All cases which came in March should use inhaler and pharmacist will
monitor the technique of the inhaler (MDI).
• All asthmatic patient whi came in March should gone through the
questionaire process in evaluating the level of knowledge.
• All health care officer who managing the patient at 3 clinics should be given
questionairre to evaluate their knowledge.


SLIDE 6 Technique of data collection
1. Questionnaire for health officer and patient (client)
2. Visit card for asthma patient is audited retrospectively to get the data
3. Analysis will be done by Pharmacist using the questionairre and interveiwing
the client.
4. Monitoring the inhaler techniquePemerhatian teknik menggunakan MDI.
5. Data will be analyze by the SPSS Vertion 16.


SLIDE 7 Inclusion criteria
- All adult bronchial asthma which registered actively since 6 months ago at
each 3 clinics in Pendang District

Exclusion criteria
- Bronchial asthma among pregnant mother


SLIDE 6 Controlled asthma based on CPG of Management of Bronchial
Asthma 2002
1. No difficulty in breathing, cough or tiredness
2. Able to do normal physical activity
3. Sleep well
4. No need to use reliever MDI
5. % Expected PEFR > 80% are expected

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SLIDE 7 Percentage of controlled bronchial asthma in Pendang District

Analysis of the data found that there were several contributing factors that led to cases
of uncontrolled bronchial asthma.


SLIDE 8 Data analyzed the factors which lead to uncontrolled bronchial
asthma
1. Weak monitoring system

Factor Standard Result

Wrong inhaler technique All patient able to perform a 41% client performed a right
correct technique technique

Defaulter tracing All defaulter cases should be call Not done


within 2 weeks from the missed
appointment date

Incorrect appointment Frequent appointment should be no


date given

2. Uneffective management

Factor Standard Result

Monitoring of PEFR Should done to all asthmatic 48% of client who have PEFR
technique is not done at patient who come to the clinic reading. Screening counter did
the counter PEFR examination should be not do the PEFR monitoring at
done at the screening counter the 3 clinics in Pendang District.

Lack of knowledge All health care officer should have 31% - Satisfactory (skor >80%)
among the health officer the knowledge about asthma. 69% - Not satisfied
in asthma management.

Failure to iniate the All asthma patient must started 82 % using inhaler
treatment with inhaler with inhaler (MDI)

CPG as the guideline is All clinic is given the Asthma CPG 42% used the guidelines
not use in managing the and target of using it is 100%
patient

No record update Inovation of the asthma No


management record book which
is more systematic and easy to
be audit.

3. Patient compliancy
Factor Standard Result

1. Did not use the MDI 100% 50% followed

2. Knowledge about asthma 100% 56% have the knowledge

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SLIDE 11 Improvement
1. Weakness in monitoring

Identifed weakness Improvement Duration

Wrong technique of 1. First consultation for all January 2010 until present
using the inhaler (MDI) 2. Demostrate the technique to all
the new patient
3. Corrected by pharmacist
4. Demonstrate by the patient
5. Evaluation by the health officer
6. 3 months and follow by year

Weak detection of 1. To establish a new appointment January 2010 until present


defaulter tracing book.
2. Defaulter case should be
contacted by the attendant using
the phone number given or by
through the nearest community
clinic.

2. Uneffective management

Identifed weakness Improvement Duration

69 % of the health care 1. 100% of the health care officer Since December 2009
officer does not have who handling the asthmatic until present
enough knowledge patient should have adequate
about asthma knowledge. (Score >80%)
2. CME is conduct by the FMS or
medical officer. All staff should
attend this CME at least once a
year.

Monitoring of the PEFR 1. Management of bronchial Since December 2009


at screening counter asthma record book should be until present
establish and PEFR record is a
must at each clinic and as the
guideline.
2. PEFR should be done at each
clinic in Pendang District

Only 82 % of patient 1. All patient need to be start with January 2010 until
using inhaler inhaler for asthma case by the present
Medical Officer or FMS.
2. Management record book
should be establish at 3 clinics in
the Pendang District
3. Random audit by FMS should
be rule out every 3 months
(systematically)

Asthma CPG is not used 1. Bronchial asthma CPG should be January 2010 until
and treatment is not develope present
based on the CPG

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SLIDE 11 3. Client conformity

Identifed weakness Improvement Duration

1. Did not use the • Inhaler technoque monitoring January 2010 until present
MDI should be monitor by the Medical
Assistant and pharmacist via the
exchange card of MDI and MDI
inspection

2. Knowledge about • Reminder about the appointment January 2010 until now
asthma date by the Asthma Educator.

3. Lack of asthma • Individual consultation with January 2010 until now


knowledge Asthma Educator every 3 months.
• FGD (Focal Group Disussion) by
pharmacist officer every 1 month
in Pendang District


SLIDE 12 % of controlled bronchial asthma cases at Pendang district before
/ after improvement


SLIDE 13 Survey Results DSA
Criteria Before After innovation After innovation
innovation 2010 2011

a. Weak monitoring
1. MDI technique 41% 71% 79%
2. Defaulter tracing 0% 64% 89%

b. Uneffective handling
montoring
1. PEFR recruitment 48% 87% 95%
2. Staff knowledge 31% 82% 86%
3. Treatment based on CPG 48% 87% 95%

a. Non - compliance
1. Patient knowledge 56% 71% 79%

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SLIDE 14 Frequency of attendance to Emergency Department before / after
improvement


SLIDE 15 Bronchial asthma cases in Pendang District

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SLIDE 16 Management of Bronchial asma patient at Pendang District


SLIDE 17 Management of Bronchial asma patient at Pendang District by
Pharmacist


SLIDE 18 ABNA

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SLIDE 19 Conclusion
1. Team work
• Management of asthma need a team work from all staff – Medical
Officer, Medical Assistant, Pharmacist and Asthma educator.
• Team work from multidiciplinary will lead to obvious good impact
2. Innovation
Management record bok for asthma patient would encourage and give
spirit to the team in handling the patient with systematic
3. CPD (Continous Process Development) :
This researh would hepl the Pendang district to control the level of asthma
effectively.


SLIDE 20 Research direction

This research is the first step of DSA team to improve and strengthening the
management of asthma all over Malaysia and also pediatric group.

References:
1. Appropriate Management Of Asthma: QAP Primary Health Care by KKM
2002: 10, 23, 24 & 25.
2. Asthma Registry Pendang.
3. CPG For Management Of Asthma KKM 2002.
4. Dr. Shahrul Bariyah Bt Ahmad. National Health And Morbidity Survey 2006
(NHMS III) Negeri Kedah Darul Aman 2008; 4,15.
5. Dr.Kuppuswamy RIyawoo. The Goal Is Total Asthma Control 2004
www.redorbit.com/news/health; 1-3.
6. Dr.Norzila Mohamed Zainudin. Asthma Control Beyond Symptoms. Issue 4,
Nov 2003.
7. Emmanouil Rovithis et al. Assessing the knowledge of bronchial asthma
among primary health care phyisician in Crete : A Pre and post test
following education course. 21 st May 2001.
8. R.Khatojia. Classifying Asthma Severity And Treatment Determinants:
National Guidelines Revisited. www.ejournal.afpm.org.my/2008v3n3/
asthma-severity, 1-3.
9. Prof Dr.Zainuddin Zin: Medical Tribune Towards Improved Asthma
Management In Asia: A Control Driven Approach. www.medical.tribune.
com by Glaxo Smith Kline.
10. www.guideline.gov/summary, 1-4.

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ELEVATE THE
PERCENTAGE OF
CONTROLLED
BRONCHIAL ASTHMA
AT HEALTH CLINIC
(PERLIS)

Training Module For Health


Care Providers

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ELEVATE THE PERCENTAGE OF CONTROLLED
BRONCHIAL ASTHMA AT HEALTH CLINIC (PERLIS)
TRAINING MODULE FOR HEALTH CARE PROVIDERS

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL


ASTHMA AT HEALTH CLINIC

SLIDE 1 Introduction

Percentage Asthma controlled 2009 - 2010

Bil Klinik Kesihatan 2009 2010


1 KK Arau 17.2% 40%
2 KK Beseri 23.3% 3.3%
3 KK Kaki Bukit 40% 0%
4 KK Kampung Gial 23.3% 23.3%
5 KK Kangar 15.7% 25.7%
6 KK Kuala Perlis 13.3% 13.3%
7 KK Kuala Sanglang 20% 16.7%
8 KK Padang Besar 10% 13.3%
9 KK Simpang Empat 80% 3.3%

SLIDE 2 Rational
Global Iniatiative For Asthma (GINA), Global Strategy For Asthma Management
and prevention 2009 (update)
• Management of asthma patient is based on level of control and not the
severity classification.
• Main aim of treatment is to achieve the target and maintain the clinical
control which included:
a. Asthma control evaluation
b. Treatment to achieve the control
c. Monitoring to maintain the control level

No Criteria Asthma QAP Perlis 2009


1 Inhaler intake 90.4%
2 Use the PEFR and record system 22.1%
3 Aware of asthma severity 98.9%
4 Aware of what to do during asthma 86.4%
attack
5 Know how to use asthma as 37.9%
prohylaxis
6 Able to demonstrate the correct 75.4%
inhaler technique
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General Objective

To elevate the monitoring of the asthma patient at Kangar district based on


GINA classification

Specific objective
• To conduct a research and study the magnitude of problem in managing
and monitoring the level of asthma control among patient.
• Identify the cause of problem in monitoring without using GINA
• Identify step of improvement
• Evaluate the steps of improvement


SLIDE 4
Indicator

Percentage of Indicator Standard


control monitoring
of asthma at Number of patient monitor according GINA
Kangar Health classification x100%
Clinic 100%
No. of active patient who securing receive
treatment

Target >50%
Achievement 17%


SLIDE 5 Model Of Good Care (MOGC)

Asthma Management

Process Criteria Standard


Registration Register in asthma registration book 100%
Monitor the level Evaluation of asthma control based on GINA 100%

Asthma education Deliver the asthma education to patient 100%


Level of control record Level of controlled is recorded in the asthma 100%
book
Treatment based on Treatment is based of level control 100%
level of controlled
Appointment date 1. After nebulized 100%
after nebulizer / follow Within 2 weeks after nebulized 100%
up date 2. Follow up
Based on GINA classification
3. Follow up treatment by Medical Assistant
or Medical Officer every 6 or 12 months.
4. Partly Control/Uncontrolled
Follow up treatment with Medical Officer
every 3 months

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SLIDE 6 Monitoring record
1. Modified the asthma record book and ensure the data regarding the asthma
controlled is documented.
2. Established the home based card with GINA classification
Improved staff knowledge
3. Training course for asthma management
• Emphasize on how to measure the level of asthma control for ach visit
• Treatment and appointment based on level of controlled
4. Training on how to evaluate asthma level according to GINA


SLIDE 7 Asthma controlled year 2009 till 2012

2012
2012
No Health Clinic 2009 2010 2011 (kriteria
(GINA)
lama)
1 KK Arau 17.2% 40% 43% 36.7% 77%
2 KK Beseri 23.3% 3.3% 6.7% 3.3% 16.6%
3 KK Kaki Bukit 40% 0% 12% 13.3% 86.7%
4 Kk Kampung Gial 23.3% 23.3% 26.7% 60% 57%
5 KK Kangar 15.7% 25.7% 16.7% 3.3% 16.7%
6 KK Kuala Perlis 13.3% 13.3% 0 56.7% 76.7%
7 KK Kuala Sanglang 20% 16.7% 46.7% 54.8% 53.3%
8 KK Padang Besar 10% 13.3% 40% 6.7% 90%
9 KK Simpang Empat 80% 3.3% 76% 83.3% 36.7%


SLIDE 8 Improvement measure conducted
1. Help the stadd on how to measure the level of asthma contril every time
the patient visit the clinic
2. Ensure all patients monitoring for each visit
3. Makesure that medical officer give the effective treatment according to the
level of control
4. Increase the quality of the asthmatic patient management in the clinic
5. Elevate the control of asthma among patient

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SLIDE 9 Global Iniatiative For Asthma (GINA), Global Strategy For Asthma Management
and prevention 2009(update)

Management of atshma composed of 4 components:


1. Component 1: Built partnership between the patient and the doctor
2. Component 2: Idetify the cause
3. Component 3: Evaluate, treat and monitor
4. Component 4: Management of asthma attack

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