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ชมรมโรคระบบหายใจและเวชบำบัดวิกฤตในเด็กแห่งประเทศไทย ร่วมกับ ยูโรดรัก ลาบอราทอรีส์. พญ.มุกดา หวังวีรวงศ์ หัวหน้าหน่วยโรคภูมิแพ้ สถาบันสุขภาพเด็กแห่งชาติมหาราชินี. Clinical Asthma Control (GINA 2006). No (twice or less/week) daytime symptoms - PowerPoint PPT PresentationTRANSCRIPT
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ชมุรมุโรคระบับัหายใจและเวัชบั'าบั�ดวั�กฤติใน้เด กชมุรมุโรคระบับัหายใจและเวัชบั'าบั�ดวั�กฤติใน้เด กแห�งประเทศ์ไทยแห�งประเทศ์ไทย
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Clinical Asthma Control (GINA 2006)
• No (twice or less/week) daytime symptoms • No limitation of daily activities, including
exercise• No nocturnal symptoms or awakening because
of asthma• No (twice or less/week) need for reliever
treatment• Normal or near-normal lung function results• No exacerbations
Asthma management program
Component 1. Develop patient/doctor partnership
Component 2. Identify and reduce exposure to risk
factors
Component 3. Assess, treat, and monitor asthma
Component 4. Manage asthma exacerbations
Component 5. Special Considerations
Levels of Asthma Control (GINA 2006)Characteristic Controlled
(All of the followings)
Partly Controlled(Any measure present in
any week)
Uncontrolled
Daytime symptoms None
(twice or less / week)
More than twice/week
Three or more
features of partly
controlled asthma present in any week
Limitations of activities
None Any
Nocturnal symptoms/awakening
None Any
Need for reliever/ rescue treatment
None
(twice or less / week)
More than twice/week
Lung function
(PEF or FEV1)***
Normal <80% predicted or personal best (if known)
Exacerbations None One or more/year* One in any week**
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
** By definition, an exacerbation in any week makes that an uncontrolled asthma week
*** Lung function is not a reliable test for children 5 years and younger
Asthma Control Test
Activities all the time most of the time
some of the time
little of the time
none of the time
Shortness of breath > 1/day 1/day 3-6/wk 1-2/wk not at all
Symptoms
at night / morning
> 4/wk 2-3/wk 1/wk 1-2/wk not at all
Use of beta-2
agonists> 3/day 1-2/day 2-3/wk < 1/wk not at all
Control rate
not controlled
poorly controlled
somewhat controlled
well controlled
completely controlled
Score 1 Score 2 Score 3 Score 4 Score 5
Asthma Control Test
Score 25 Total control
Score 20-24 Well controlled
Score <20 Not be controlled
Childhood Asthma Control Test
How is your asthma?
Very bad Bad Good Very good
Playing / exercises
Can’t do Don’t like A little problem
No problem
Cough All the time Most of the time
Some of the time
None of the time
Wake up at night
All the time Most of the time
Some of the time
None of the time
Score 0 Score 1 Score 2 Score 3
Children Asthma Control Test
Daytime symptoms
everyday 19-24 11-18 4-10 1-3 0
Daytime wheeze
everyday 19-24 11-18 4-10 1-3 0
Wake up at night
everyday 19-24 11-18 4-10 1-3 0
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5
Childhood Asthma Score
Score < 19 Not well controlled
Score > 20 Under controlled
Management Approach Based On ControlFor Children Older Than 5 Years, Adolescents and Adults
(GINA 2006)
Control Maintain and find lowest controlling step
Partly controlled Consider stepping up to gain control
Uncontrolled Step up until controlled
Exacerbation Treat as exacerbation
Level Control Treatment Action
Increase
Red
uce
ReduceTreatment Steps Increase
Asthma education & Environment controlAs needed
rapid acting
β2-agonist
As needed rapid acting β2-agonist
Controller
options
Select one Select one Add one or more Add one or both
Low- dose
inhaled ICS*
Low-dose ICS
plus long-acting β2-agonist
Medium or high-dose ICS plus long-
acting β2-agonist
Oral glucocorticosteroid
(lowest dose)
Leukotriene
modifier**
Medium or
high dose ICS
Leukotriene
modifier Anti-IgE treatment
Low dose ICS plus
Leukotriene modifier
Sustained release
theophylline
Low dose ICS plus
sustained- release theophylline
Step 1 Step 2 Step 3 Step 4 Step 5
*ICS = Inhaled glucocorticosteroids
** = Receptor antagonist or synthesis inhibitors
The first 3 drugs used for asthma controlThe first 3 drugs used for asthma control (N = 171)(N = 171)
1 LB2
LL39/882
3783 LL2
76171 - 099 052189 0973. ( . . ) . (4 4 .3 2 ) 4458( . ) 4444( . )
2 3 488 LL 3183 6 5171 - 106 054205 0862. ( . . ) . 3864( . ) 3735( . ) 3801( . )
3 8 88 LLLL 1383 LLLL 21171 - 054 019149 0191. ( . . ) . 909( . ) 1566( . ) 1228( . )
Drug N (%) Drug N (%) Drug N (%) L LL / SH Total OR (95% CI) P
RH = Regional hospital
PH = Provincial hospital
SH = Small hospitalVangveeravong M.Thai Pediatr J 2005; 12(1);25-32.
The first The first 33 drugs used for asthma control drugs used for asthma control by different kinds of doctorsby different kinds of doctors
((NN = 172)= 172)
1 1320IS / LL2
4395 LL2
2757 - 029 007097 0027. ( . . ) . LB2
650( . ) 4526( . ) 4737( . ) 2 LB
2 420 LL 3695 1 857 - 337 1161002 0011. ( . . ) . IS
200( . ) 3789( . ) 3157( . ) 3 320KETO / LLLL 1095 LLLL 1257 - 000 000131 0068. ( . . ) . THEO
150( . ) 1053( . ) 2105( . )
Drug N (%) Drug N (%) Drug N (%) OR (95% CI) P Drug
LLL NG Others (O) Ped : NG + O
Ped = PediatriciansPed = Pediatricians
NG = Newly graduated doctorsNG = Newly graduated doctors
LLLL0 .0 0 0
Vangveeravong M.Thai Pediatr J 2005; 12(1);25-32.
NN
N
N
O H
H
O
H
N
NN
N
O H
O
H3C
CH3
O
N
N
N
N
O
O
O
CH2
H3C
CH3
XANTHINE
THEOPHYLLINE
DOXOPHYLLINE
Methylxanthinespostulated mechanism of action
Increased cyclic AMP levelby inhibiting phosphodiesterase-4 (PDE-4)
ACAC PDE-4
c’APM c’APM ATPATP 5’AMP5’AMP
Bronchodilatation
(+) (-)
β2-agonistsβ2-agonists XanthinesXanthines
Bronchodilating actions
• Inhibit C’ nucleotide phosphodiesterase (PDEs)
• Antagonize receptor-mediated actions of adenosine
Adenosine - bronchoconstriction
- potentiate immunologically induced mediator release from human lung mast cells
Bronchoprotective actions
• Reduction of airway responsiveness to “specific” challenges with allergen
Hendeles et al. J Allergy Clin Immuno 1995; 95:505.
• Against non-specific stimuli - exercise Pollock et al. Pediatrics 1977;60:840.
- fog Allegra. Eur J Respir Dis 1980;61(S),106:41.
- SO2 Koenig et al. J Allergy Clin Immunol 1992; 89:789.
Anti-inflammatory actions
• Inhibition of LTs release from the airways Rabe et al. Am J Crit Care Med 1995;151(S):338 abstract
• Attenuation of the effects of LTD4 at its receptors
Howell. J Pharmacol ExpTher 1990; 225:1108
• Blockade of adenosine-induced mediator release in mast cells
Welton&Simko. Biochem Pharmacol 1980; 29:1085
• Attenuation of late phase airway obstruction in airway response to histamine, in allergics
Hendeles. JACI 1995; 95 :505.
Anti-inflammatory actions
• Decrease of the allergen induced migration of eosinophils into the airway mucosa
Sullivan et al. Lancet 1994;343: 1006.
• Restoration of corticosteroid responsiveness by activation of histone deacetylase (HDAC) and consequent suppression of inflammation
Cosio et al. J Exp Med 2004.
• Decrease of microvascular leakage of plasma into the airway
Erjefalt & Persson. Acta Physiol Scand 1986; 128:653
• Decrease of neutrophils and LTB4 at nights in asthmatics
Kraft et al. Am J Crit Care Med 1996; 154 :1505.
Pulmonary system• Relax airway smooth muscles Rabe et al. Am Rev Respir Dis 1993; 147(S):A 184, abstract.
• Relax smooth musles in pulmonary arteries
Hendeles & Weinberger. New Engl J Med 1996; 334:1380.
• Reduce decrease in lung function at night in asthmatics
Kraft et al. Am J Crit Care Med 1996; 154:1505.
Pulmonary system
• Decrease fatigue in diaphragmatic muscles
Merciano et al. New Engl J Med 1984 ; 311:349.
• Increase mucociliary clearance Cotromanes et al. Chest 1985; 88:194.
• Block (centrally-acting) decrease in ventilation during hypoxia
Easton & Anthonisen. J Appl Physio1998; 64:1445.
Preventive Bronchodilatation Anti-inflammatory
Cromoglycate +++Nedocromil ++Ketotifen ++β2-agonists + +++Anticholinergics + +++Corticosteroids +++Antileukotrienes + ++Methylxanthines ++ +++ ++