guideline asthma 2008

8/12/2019 Guideline Asthma 2008

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26(8)

50(1) (3) ..2545

( )

2551

: : .. 2551

1 2552

5,000

National Library of Thailand Cataloging in Publication Data

.. 2551. : .. 2551.--

: , 2552118 .

1. ----. 2. ----. I. .

616.238ISBN 978-611-7197-01-7

:

(.)120 3 2-4 . 10210 0-2141-4000 0-2143-9730www.nhso.go.th

: 0-2214-4660 0-2612-4509


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() 3 .. 2547

.. 2551


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Chronic inflammation chronic inflammation airway remodeling airway remodeling (airway hyper-responsiveness)

(irreversible airway obstruction)

( ) ( )

()

( )

( )

( )


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.. 2551 .. 2551

3 3.1 (descriptive studies) 3.2 (fair-designed, controlled

clinical trial) 4

4.1 (consensus)

4.2

2 (anecdotal report)

(Quality of Evidence) 1

1.1 (systematic review)

- (randomize-controlled, clinicaltrials)

1.2 - 1 (a well-designed, randomize-controlled,clinical trial)

2

2.1 (non-randomized-controlled, clinical trials)

2.2 (well-designed, non-randomized-controlled, clinical trial)

2.3 (cohort) (casecontrol analytic studies) (case control analytic studies) /

2.4 (multiple time series)

.. 2480


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.. 2551 .. 2551

.. 2551

3

3 4 5

5

6 6

8 8 9

10

11

11

AIA Aspirin-induced asthmaDPI Dry powder inhalerFVC Forced vital capacityHEPA High efficiency particulate air filterICS Inhaled corticosteroid

LABA Long-acting !2-agonistMax MaximumMin MinimumMDI Metered-dose inhalerNB Nebulized solution (respiratory solution, respules)NSAIDs Non-steroidal anti-inflammatory drugs

PEF Peak expiratory flowSABA Short-acting !

2- agonist


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.. 2551 .. 2551

56 57 57

57 58 58

61 61 61

61

62 65

65

65 66 66 73 74 allergen immunotherapy 79

80 asthma exacerbation 82 asthma exacerbation 85 87

88

89 89

13 14 14

17 20 21

29 30 33

33 34

34 35 35 35

36 37 38

PEF variability 38 PEF

38Asthma Control Test (ACT)

41 52

.. 2551 55

56


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.. 2551

25441

( 12,219 20 44 6.8 4.0 - -

2)25452

( 3,454 20 44 16.4 3.25 3.31 2.91

2)

(bronchial hyper-responsiveness, BHR)

1

1

..

(%)

()

()

(%)

(%)

BHR

(%)

3 .. 2551


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8 9 .. 2551 .. 2551

FEV1 methacholine

(methacholine challenge test)12 ( 2, ++)

corticosteroid ( ++) ( ++) airway remodeling ( ++)

1. 2.

3. 4. 5.

1.

2.

3.

4.

5. (asthmaexacerbation)

6. 7.

1.

1.

2. 3.

( ++)

4. peak flow meter


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10 11 .. 2551 .. 2551

5.

( ++)

2.

(++)

1. (allergen)

2.

3.

4. NSAID aspirin !-blocker5.

6. 7.

8.

indoorpollutant ( +/-) allergic rhinitis ( ++)

3.

3.1 10, 13

corticosteroid intermittent persistent asthma 2


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12 13 .. 2551 .. 2551

> 80 %< 20 %

> 80 %

< 20 -30 %

60 - 80 %> 30 %

< 60 %

> 30 %

2 10, 13

PEF or FEV1

PEF variability

1

Intermittent

2

Mild persistent

3

Moderate persistent

4

Severe persistent

- 1

-

- PEF

-

1 1

-

- -

-

-

-

2

-

2

-

1

-

3.2

(controller)

Asthma Control Test (ACT)14( 1, ++) Asthma Control Questionnaire (ACQ)15 ( 1, ++)

3 (3) (controlled)

(relievers) 16(partly controlled) (uncontrolled)


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14 15 .. 2551 .. 2551

( 2

2 ) partly controlled

3

reliever/ ( 2

rescue treatment 2 )

80%

predicted or personal

(PEF or FEV1) best (if known)

1 1 (Exacerbation)*

3

*

Controlled Partly Controlled

( ( 1 Uncontrolled

) )

4.

4.1 (controller) (reliever) 4

4 13

CONTROLLER

MEDICATIONS1. Corticosteroid

2. Long-acting

!2-agonist*(LABA)

beclomethasone budesonide fluticasone prednisolone( ) hydrocortisone dexamethasone methylprednisolone

salmeterol** formoterol***

ANTI-INFLAMMATORYAGENT

inflammatory cell inflammatorycell17(1, ++)

mucus

!

2-agonist

18( 2, ++)

corticosteroid

neutrophilic airwayinflammation 19-20( 1, ++)


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16 17 .. 2551 .. 2551

2. Methylxanthine

3. Anticholinergic

!

2-agonist

terbutaline

salbutamol terbutaline procaterol aminophylline

ipratropium bromide+ fenoterol salbutamol

3. ICS LABA

4. Leukotriene

modifier

5. Xanthine(sustained release)

6. Anti-IgE

RELIEVERMEDICATION1. Short-acting!

2-agonist

microvascular

leakage

ICS LABA

leukotriene corticosteroid

IgE IgE mast cells basophils

salmeterol fluticasone

formoterol budesonide

montelukast

theophylline doxofylline

(omalizumab)

salbutamol terbutaline procaterol fenoterol salbutamol

* long-acting !2-agonist

inhaled corticosteroid ( ++)** acute asthma

( -)*** short-acting

!2-agonist

4.1.1 (controller)

1. Corticosteroid

Corticosteroid ( ++) glucocorticoid receptor inflammatory cell

cytokine


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22 23 .. 2551 .. 2551

controlled uncontrolled controlled !2-agonist (

++) !2-agonist ICS controller ( ++)

6 *

* Global Initiative Asthma 2006

Reduce Treatment Steps Increase

Step 1 Step 2 Step 3 Step 4

Asthma educationEnvironmental control

As neededrapid-acting

!2-agonist

As needed rapid- acting !2-agonist

Leukotrienemodifier

Medium-or-high-dose ICSLow-dose ICSplus leukotriene

modifierLow-dose ICSplus sustained

releasetheophylline

LeukotrienemodifierSustainedrelease

theophylline

Controlleroptions

Select one Select oneAdd one or

more

Low-doseinhaled

ICS*

Low-dose ICSplus

long-acting!

2-agonist

Medium-or-high-dose ICS

plus

long-acting!

2-agonist

* ICS-inhaled glucocorticosteroid

Step 5

Add one orboth

Oral glucocor-ticosteroid

(lowest dose)

Anti-lgEtreatment


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26 27 .. 2551 .. 2551

5 ( 4 1 2)

5

4 !2-agonist

controller 4 corticosteroid 51(

4, +) anti-IgE allergic

asthma 52-57

( 1, ++)4 5

4.2.2

controller

3 - 4 16, 58

4.2.3 10, 13

(assessing asthma control) (1) (treating to achieve control) (monitoring tomaintain control) ( ++)

1

Assessing asthma control

Treating toachieve control

Monitoring tomaintain control

(Stepping down treatment)

1. corticosteroid

3 corticosteroid 50% 3 59-61( 1,

++) corticosteroid corticosteroid ( 1, ++)62-63

2. corticosteroid long-acting!

2-agonist 3

- corticosteroid 50%


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30 31 .. 2551 .. 2551

1. oxygen oxygen nasal cannula mask O

2

saturation > 90%

69

( 1, ++)2. (PEF > 50%

) rapid onset !2-agonist nebulizer70-72(

1, ++) MDI spacer73

( 1, ++) nebulizer

0.5 1 . (salbutamol 2.5 5 .) MDI spacer 2 puff 15 30 16puff 4 6 nebulizer 15 30 4 6 ( ++)

2

2

National Asthma Education and Prevention Program. Expertpanel report 2: Guideline for the diagnosis and management of asthma.

Bethesda, MD: National Institutes of Health, 1997; .55: 4051

Reassessment in 1 hr

Reassessment in 12 hr

PEFR > 50%O

2to achieve SaO

2> 90%

!2-agonist MDI (spacer) q 10 min

or nebulize q 20 min in 1 hrSystemic corticosteroid

PEFR < 50%O

2to achieve SaO

2> 90%

!2-agonist +anticholinergic

nebulize q 20 min in 1 hrSystemic corticosteroid

PEFR 5080%!2-agonist + anticholinergic

nebulize q 60 min for 13 hrSystemic corticosteroid

PEFR < 50%!2-agonist + anticholinergic

Consider IV aminophylline, MgSO4Systemic corticosteroid

Good response(PEFR > 70%)

Discharge

Incomplete response(PEFR 5070%)Admit ward

Initial assessment (History, Physical exam & PEFR)

Poor response(PEFR < 50%)Admit ICU


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36 37 .. 2551 .. 2551

( ++)

7.3

bronchial hyper-responsiveness

FEV

1 80

systemic corticosteroid systemiccorticosteroid 6 corticosteroid

24 (+)

bronchial hyper-responsiveness

corticosteroid airway hyper-responsiveness airway remodeling

peak flow meter ACT


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1. PEF variability PEF 11

morning pre-bronchodilator PEF 1 PEF (3)

3 morning pre-bronchoditator PEF

PEF variability

2. Asthma Control Test (ACT).14

PEF min x 100PEF max

Nathan Asthma Control Test (ACT) (4)

4 1 5 ( = 5 = 1) Nathan ACT ACT sensitivity specificity (uncontrolled) 19 25 20 24

4 Asthma Control Test (ACT)


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(partly controlled) 19 (uncontrolled) sensitivity specificity ACT (uncontrolled) score 20 ACT 25 21 24 controlled partly controlled 20 uncontrolled (5)

5 Asthma Control Test(ACT)

1. Boonsawat W, Charoenphan P, Kiatboonsri S et al. Survey ofasthma control in Thailand. Respirology 2004; 9:373-378.2. Dejsomritrutai W, Nana A, Chierakul N, et al. Prevalence of bron-

chial hyper-responsiveness and Asthma in the adult populationin Thailand. Chest 2006; 129:602-609.

3. . . . . 2537.

4. . (). . 2540.

5. . (). . 2547; 19:179-193.

6. Larche M, Robinson DS and Kay AB. The role of T lymphocytes

in the pathogenesis of asthma. J Allergy Clin Immunol 2003;111:450-463; quiz 64.

7. Maneechotesuwan K, Xin Y, Ito K, et al. Regulation of Th2 cytokinegenes by p38 MAPK-mediated phosphorylation of GATA-3.J Immunol 2007; 178:2491-2498.

8. Jatakanon A, Lim S and Barnes PJ. Changes in sputum eosino-

phils predict loss of asthma control. Am J Respir Crit Care Med2000; 161:64-72.

9. Busse WW and Lemanske RF, Jr. Asthma. N Engl J Med 2001;344:350-362.

10. Global Initiative for Asthma. Asthma management and preventionprogram. Global strategy for asthma management and prevention(updated 2006). Bethesda, MD US Department of Health and


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76 Lanes SF Garrett JE Wentworth CE 3rd Fitzgerald JM and randomized study Intern Med 2000; 39:794-797


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50 51 .. 2551 .. 2551

76. Lanes SF, Garrett JE, Wentworth CE, 3rd, Fitzgerald JM andKarpel JP. The effect of adding ipratropium bromide to salbutamolin the treatment of acute asthma: a pooled analysis of threetrials. Chest 1998; 114:365-372.

77. Rodrigo GJand Rodrigo C. First-line therapy for adult patientswith acute asthma receiving a multiple-dose protocol ofipratropium bromide plus albuterol in the emergency department.Am J Respir Crit Care Med 2000; 161:1862-1868.

78. Parameswaran K, Belda Jand Rowe BH. Addition of intravenous

aminophylline to beta2-agonists in adults with acute asthma.Cochrane Database Syst Rev 2000:CD002742.79. Rowe BH, Bota GW, Fabris L, Therrien SA, Milner RAand Jacono

J. Inhaled budesonide in addition to oral corticosteroids toprevent asthma relapse following discharge from the emergencydepartment: a randomized controlled trial. JAMA 1999; 281:

2119-2126.80. Manser R, Reid Dand Abramson M. Corticosteroids for acute

severe asthma in hospitalised patients. Cochrane Database SystRev 2001:CD001740.

81. Harrison BD, Stokes TC, Hart GJ, Vaughan DA, Ali NJ andRobinson AA. Need for intravenous hydrocortisone in addition

to oral prednisolone in patients admitted to hospital with severeasthma without ventilatory failure. Lancet 1986; 1:181-184.

82. Ratto D, Alfaro C, Sipsey J, Glovsky MMand Sharma OP. Areintravenous corticosteroids required in status asthmaticus? JAMA1988; 260:527-529.

83. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic

corticosteroids in the treatment of asthma exacerbation; a

randomized study. Intern Med 2000; 39:794-797.84. Watchara Boonsawat, Uraiwan Zaeoui, Sunee Lerdsinudomand

Chanee Samosorn. Implementation of GINA guidelines througheasy asthma clinic. Respirology (2007)12, (suppl 4) A147.

85. (Easy Asthma Clinic). In: , , eds. 5th BGH Annual academicmeeting:From the basic to the top in medicine. : .; 2548:83-87.


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:

:

:


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1. Airway inflammation

2. Structural changes in the airways (airway remodeling)3. Bronchial hyper-responsiveness4. Variable and partially reversible airway obstruction

/

1. ( ++)

1.1

1.2

1.3 atopic dermatitis,allergic rhinitis

1.4

Cough-variant asthma

peak expiratory flow bronchialhyper-responsiveness

.. 2551

4.5 (.

.. 2530) 12.7 (. .. 2538) 9.05 (.. 2538) 10.06 ( .. 2542) 4.0 .. 2529-2533 (anti-inflammatory drugs) 1.9 .. 2540-2544

(bronchial hyper-responsiveness) (variable airflow obstruction) (wheeze)


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58 59 .. 2551 .. 2551

- PEF variability > 20%- PEF variability = PEF max PEF min

1/2

(PEF max + PEF min)3.2

1) allergy skin test, serumspecific IgE

2) bronchial hyper-responsiveness methacholine, histamine, mannitol exercise challengetest

3) airway inflammation non-invasive sputum eosinophil, exhaled nitric oxide, exhaledcarbon monoxide

< 5

1. (> 1 )2.

3. 4. 3

x 100%

1. 2. 3. 4.

5.

(> 10 )6.

2. 2.1 (wheeze)

2.2

2.3 2.4

allergic rhinitis, allergic conjunctivitis atopic dermatitis3.

3.1 5

( +)1) Spirometry FEV1 FVC

- FEV1 > 12 % > 200 . (pre andpost bronchodilator)

- FEV1/FVC ratio < 0.752) Peak expiratory flow (PEF)

- PEF > 20 % (pre and post bronchodilator)


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60 61 .. 2551 .. 2551

1. 2. 3. 4.

5.

6.

5

1.

2. 3.

4. 5.

1.

3

1. (Atopic dermatitis)

2. 2 2.1 allergic rhinitis2.2 2.3 CBC eosinophilia (> 4%)

(Therapeutic trial) ( +):

short acting !2-agonist

inhaled corticosteroids

recurrent wheezing

(< 5 ) 1. Chronic rhinosinusitis2. Gastroesophageal reflux3. Recurrent lower respiratory tract infections4. Congenital heart diseases5. Bronchopulmonary dysplasia

6. Tuberculosis7. Congenital malformation causing narrowing of the

intrathoracic airways8. Foreign body aspiration9. Immune deficiency10. Primary ciliary dyskinesia syndrome11. Cystic fibrosis


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step

leukotriene modifier ( +)


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68 69 .. 2551 .. 2551

difficult-to-treat asthma

medium-dose ICS

LABA ( ++) leukotriene modifier sustained-release theophyllinehigh-dose ICS LABA 3 6 corticosteroids 2

5 (4 1 2)

step 4 oral corticosteroids step 4

corticosteroids anti-IgE oral corticosteroids

ICS ICS

sustained-release theophylline ( +) cromone (sodium cromoglycate)

3 ( )

low-dose ICS long-acting !2-agonist (LABA) (

++) low-dose inhaled ICS 3 - 4 ICS uncontrolled partly controlled

formoterol LABA

formoterol reliever controller step 3 medium-doseICS ( ++) MDI spacer

low-dose ICS leukotriene modifier ( +) low-dose ICS

sustained-release theophylline ( +) 2 (< 5 )

4 ( ICS LABA )

(

+)

2 < 5 1 > 5


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70 71 .. 2551 .. 2551

* leukotriene modifier may be particularly useful if the patient has concomitant rhinitis** Check compliance, allergen avoidance and re-evaluate diagnosis*** Check compliance and consider referring to specialist

S

tep

up

therapy

to

gain

control

Stepdownifappro

priate

Stepdownifapp

ropriate ICS or leukotriene modifier*

(200 mcg BDP equivalent) (dose depend on age)

Insufficient control**

Increase ICS or Add ICS to(400 mcg BDP equivalent) leukotriene modifier

Insufficient control**

Increase ICS dose (800 mcg BDP equivalent)or

Add ICS to leukotriene modifieror

Add LABA

Insufficient control***

Consider other options- Theophylline

- Oral corticosteroids

Level of Control

Controlled

Partly controlledUncontrolledExacerbation

Maintain and find lowest controlling step

Consider stepping up to gain controlStep up until controlledTreat as exacerbation

Treatment Steps

Asthma educationEnvironmental control

As needed short

acting !2-agonist

Controller

options

As needed short acting !2-agonist

Select one

Low-dose inhaled

ICS*

Leukotriene

modifier**

Select one

Low-dose ICS

plus Long acting!

2-agonist

Medium-or

high-dose ICS

Low-dose ICS plus

Leukotriene modifier

Low-dose ICS plus

sustained release

theophylline

Add one or more

Medium-or high-

dose ICS pluslong acting

!2-agonist

Leukotriene

modifier

Sustained release

theophylline

Treatment ActionR

ed

uce

Increase

Reduce Increase

Step 1 Step 2 Step 3 Step 4

Add one or both

Oral

glucocorticosteroid(lowest dose)

Anti-IgE

treatment

* ICS = inhaled glucocorticosteroids** = Receptor antagonist or synthesis inhibitors

Step 5

:

4.2 (monitoring to maintain control)

8 inhaled corticosteroids

(equivalent dose)


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72 73 .. 2551 .. 2551

1 3 3 controlled 6

step down controlled

1. controlled medium-to highdoseICS 3 50%

2. controlled low-dose ICS

3. controlled ICS LABA ICS 50% 3 low-dose ICS LABA < 5 LABA ICS

4. controlled ICS ICS 50% 3 low-dose ICS

5. controlled 1

Drug Low Daily Medium Daily High Daily

Dose (mcg) Dose (mcg) Dose (mcg)Beclomethasone dipropionate 100 200 > 200 400 > 400- MDI (50, 100, 200, 250 mcg)- DPI (Easyhaler; 200 mcg)Budesonide 100 200 > 200 400 > 400- MDI (100, 200 mcg)

- DPI (Easyhaler, Turbuhaler,Swinghaler; 100, 200 mcg)

- Nebulized solution (500,1000 mcg)

Ciclesonide 80 160 > 160 320 > 320- MDI (80, 160 mcg)

Fluticasone propionate 100 200 > 200 500 > 500- MDI (50, 125, 250 mcg)- DPI (Accuhaler; 100,

250 mcg)- Nebulized solution (500,

2000 mcg)Mometasone furoate 100 200 > 200 400 > 400- DPI (220 mcg)

(equivalent dose)

: combination of salmeterol + fluticasone: .. 2551 4


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78 79 .. 2551 .. 2551

10

10

< 4 MDI plus spacer with face mask Nebulizer with face mask

4 - 6 MDI plus spacer with mouthpiece Nebulizer with mouthpiece

> 6 DPI Nebulizer with mouthpiece

MDI plus spacer with mouthpiece

: DPI accuhaler, easyhaler, turbuhaler

swinghaler Spacer corticosteroid spacer valve

valve spacer mouth piece

allergen immunotherapy

Allergen immunotherapy allergic asthma

1. 2. 3. 4.

/

4.Sustained-release

theophylline

5.Anti-IgE

/tab

-Theophylline

-Omalizumab

-5-6mg/kg/dose1

2

,600mg/day

-

IgE

-

-anaphylacticreaction

2

-

-

-12

inhaledcorticosteroid

s

Mild Moderate Severe

respiratory

5. asthma exacerbation


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80 81 .. 2551 .. 2551

2 - 12 < 160 /1 2 < 120 /2 8 < 110 /

PEF

(% predicted

personal best)

PaO2(on air)

/

PaCO2

(on air)

SaO2% (on air)

> 80 %

< 45 mm Hg

> 95 %

60 80%

> 60 mm Hg

< 45 mm Hg

91 95 %

< 60%

< 60 mm Hg

(cyanosis)

> 45 mm Hg

< 90 %

respiratoryarrest

(/) < 100 100 120 > 120

asthma exacerbation 1111 asthma exacerbation

Mild Moderate Severe

30 /

< 2 < 60 /2 12 < 50 /1 5 < 40 /6 8 < 30 /

suprasternal

retraction

wheeze

end expiratory

respiratoryarrest

Paradoxicalthoraco-

abdominal

movement

wheeze

* MDI with spacer DPI

5.1 asthma exacerbation 3


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82 83 .. 2551 .. 2551

1

(1)

(2) inhaled short acting!2-agonist

(3) (4)

3 asthma exacerbation

,

4

PEF > 80%predicted personal

best

- inhaled SABA 2 4

puffs 3 4

24 48

12

Inhaled SABA* 2 4 puffs/dose3 20

3 PEF 60-80%

predicted personal

best

- inhaled SABA

6 10 puffs 1 2

PEF

< 60% predicted personal best

- inhaled SABA

6 10 puffs 1 2


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(6) -

(4) systemic corticosteroids


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86 87 .. 2551 .. 2551

- (mucolytic)

-

- asthma exacerbation

5.3

(1) (2) 1 - 3

(PEF < 70%predicted personal best oxygen saturation < 95%)

(3) (high risk)

- near fatal asthma ventilator-

- prednisolone

- !2-agonists ( 1 )-

3 - 4 prednisolone 0.5 - 1 ././ 40 ./ 3 - 5

hydro-cortisone 5 ././ 6 100 ./ methylprednisolone 1 ././ 6 40 ./ hydrocor tisone methylprednisolone systemic corticosteroid prednisolone 3 - 5 taper off steroid

nebulized ICS acuteexacerbation ICS ICS

(5) - Epinephrine 1:1000 (adrenaline) 0.01 ./.

0.3 .

- SABA NB MDI

- anaphylaxis angioedema - Aminophylline 5 ./. loading dose IV drip 1 ././. loading dose 5 - 15 ./.


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3. (tertiary prevention)


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96 97 .. 2551 .. 2551

1. , , ,

. .. 2543 . 2543; 39:172-197.

2. . .. 2548.

3. American Academy of Pediatrics, Subcommittee on Managementof Sinusitis and Committee on Quality Improvement. Clinicalpractice guideline: management of sinusitis. Pediatrics 2001;108:798-808.

4. British guideline on the management of asthma. Thorax 2003; 58

(Suppl 1):i1-94.5. Boonyarittipong P, Tuchinda M, Balangkura K, Visitsunthorn Nand Vanaprapar N. Prevalence of allergic diseases in Thaichildren. J Pediatr Soc Thai 1990; 29:24-32.

6. Bousquet J, Van Cauwenberge P and Khaltaev N, ARIA WorkshopGroup, World Health Organization. Allergic rhinitis and its

impact on asthma. J Allergy Clin Immunol 2001; 108(Suppl 5):S147-S334.

7. Bousquet J, Van Cauwenberge P and Khaltaev N. Allergic rhinitisand its impact on asthma (ARIA)- Executive summary. Allergy2002; 57:841-855.

8. Global Initiative for Asthma. Global Strategy for Asthma

Management and Prevention, NHLBI/WHO workshop report.

(7)


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guideline asthma 2008

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