On behalf of the SINA panel Mohamed S. Al-Moamary , FRCP (Edin) FCCP

1. The Saudi Initiative for AsthmaGuidelines for the Diagnosis and Management of Asthma in Adults and Children2013 update Management of Acute Asthma in Adults On behalf of the SINA panel Mohamed S. Al-Moamary, FRCP (Edin) FCCP Dep. of Medicine, King Abdulaziz Medical City-Riyadh King Saud bin Abdulaziz University for Health Sciences

2. Management of Acute Asthma in Adults Enter presenter name Enter the presenter’s institute

3. What is SINA? • SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society • SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist. • International recommendations were customized to the local setting for asthma diagnosis and management • Directed to HCW dealing with asthma who are not specialists in the field.

4. Purpose of SINA • To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians

5. Where do you find SINA? • The SINA guideline was published in the Annals of Thoracic Medicine (www.thoracicmedicine.org): Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:175-204 • The SINA guidelines booklet is available at: www.sinagroup.org

6. Saudi Thoracic Society commitment • The STS is committed to improve the care of asthma by a long term plan: • Periodic scientific meetings • Annual asthma meeting (since 2001) • Frequent asthma courses • Educational brochures • Publishing new and updated asthma guidelines

7. What is new in SINA-2012 • Comprehensive revision with the addition of new 125 references • Addition of charts and algorithms for asthma diagnosis and management • Updating asthma management • Rewritten “asthma in children” section • New section on “difficult to treat asthma”

8. SINA Panel • Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, Riyadh • Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh • Mohamed S. Al-Hajjaj, King Saud University, Riyadh • Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, Riyadh • Majdy M. Idrees, Military Hospital, Riyadh • Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh • Adel S. Alharbi, Military Hospital, Riyadh •  Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam • Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah •  Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh

9. Acknowledgment The SINA panel would like to thank the following reviewers : • Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada • Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and the Montreal Chest Research Institute • Prof. Sheldon Spier, the University of British Columbia, Vancouver, Canada • Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa (SINA 2009) • Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)

10. SINA Documents • Published manuscript • Booklet • Electronic version • Slides kit • Flyers • Website: www.sinagroup.org

11. Sections of SINA – update cover • Epidemiology • Pathophysiology • Diagnosis • Medications • Approach to Management • Treatment Steps • Special Situations • Acute Asthma

12. Prevalence • Prevalence of asthma has increased between 1986 – 1995 Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296

13. Burden of Asthma • Asthma is among the most common chronic illnesses in Saudi Arabia • 53% had missed school or work (AIRKSA-2007) • 35% attempted Unconventional therapy (Al Moamary, ATM 2008) • 46% were controlled in Riyadh (AIRKSA-2007) • 36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008) • 48% were controlled in one center (Al Moamary, ATM 2008)

14. AIRKSA report (Ministry of Health) • 78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA) • 54 % of adults & 80% of kids reported ER over 12 months (AIRKSA) • 45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA) • 76 % of adults & 78% of kids never had spirometry(AIRKSA)

15. The prevalence of wheeze and associated symptoms in the study group Al-Ghobain et al, NBC Pulm Med 2012;12:39

16. Pattern of asthma treatment Al-Shimemeri, Ann Thorac Med 2006;1:20-5

17. Pathology of Asthma Inflammation Airway Hyper-responsiveness Airway Obstruction Symptoms of Asthma

18. Pathophysiology

19. Inflammation  Remodeling • Inflammation • Airway Hypersecretion • Subepithelial fibrosis • Angiogenesis

20. Diagnosis - History • Episodic attacks: • Cough • Breathlessness • Wheezing • Nocturnal symptoms • Patient could be asymptomatic between attacks • co-existent conditions: GERD, rhinosinusitis.

21. Relevant Questions • Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis? • Does the patient have recurrent attacks of wheezing? • Does the patient have a troublesome cough at night? • Does the patient wheeze or cough after exercise? • Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?

22. Relevant Questions • Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers? • Does the patient's cold “go to the chest” or take more than 10 days to clear up? • Are symptoms improved by appropriate asthma treatment? • Are there any features suggestive of occupational asthma

23. Physical Examination • Normal between attacks • Bilateral expiratory wheezing • Examination of the upper airways • Other allergic manifestations: e.g., atopic dermatitis/eczema • Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing

24. Investigations • Measurements of lung function: • Spirometry • Peak expiratory flow (PEF) • Normal Spirometry does not role out asthma • Spirometry is superior to PEF

25. Bronchodilator response • Proper instructions on how to perform the forced expiratory maneuver must be given to patients, and the highest value of three readings taken. • The degree of significant reversibility is defined as an improvement in FEV1 ≥12% and ≥200 ml from the pre-bronchodilator value.

26. Clinical Assessment • Measurements of allergic status to identify risk factors (if indicated) • Chest X-ray is not routinely recommended • Routine blood tests are not routinely recommended • IgE measurement is indicated in severe cases

27. Assessment of Asthma Control

28. Asthma Control Test Level of Control: • Total: 25 • Control: 20-24 • Partial control: 16-19 • Uncontrolled: < 16

29. Differential Diagnosis • Upper airway diseases • Allergic rhinitis and sinusitis • Obstructions involving large airways • Foreign body in trachea or bronchus • Vocal cord dysfunction • Vascular rings or laryngeal webs • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis • Enlarged lymph nodes or tumor • Obstructions involving small airways • Viral bronchiolitis or obliterative bronchiolitis • Cystic fibrosis • Bronchopulmonary dysplasia • Heart disease • Other causes • Recurrent cough not due to asthma • Aspiration from swallowing mechanism dysfunction or GERD

30. Management of Acute Asthma

31. Acute Asthma in Adults • Most patients who present with an acute asthma exacerbation have chronic uncontrolled asthma • The following should be carefully checked: • previous history of near fatal asthma • patient taking three or more medications • heavy use of SABA and frequent ER visits • Patient should be assessed to determine the severity of acute attacks • PEF and pulse oximetry measurements are complementary to history taking and physical examination

32. Levels of severity of acute asthma exacerbations in adults

33. Initial Assessment of Acute Asthma

34. Medications used in acute asthma Oxygen • High concentration of inspired oxygen to correct hypoxemia (do not miss COPD) • Pulse oximetry should be used to tailor oxygen therapy • Failure to achieve oxygen saturations of more than 92% is a good predictor of the need for hospitalization • Normal or high PaCO2 is an indication of a severe attack, and need for specialist consultation

35. Bronchodilators • Inhaled salbutamol is the preferred choice • Repeated doses is recommended at 15–30 minute intervals. • Alternatively, continuous nebulization (Salbutamol at 5–10 mg/hour) may be used for one hour if there is an inadequate response to initial treatment.

36. Bronchodilators • Patients who are able to use the inhaler devices, 6–12 puffs of MDI with a spacer are equivalent to 2.5 mg of Salbutamol by nebulizer • In moderate to severe acute asthma, combining ipratropium bromide with Salbutamol has some additional bronchodilation effects, in reducing hospitalizations and greater improvement in PEF or FEV1

37. Steroid therapy • Systemic steroids: reduce relapses and subsequent hospital admission • Oral steroid = injected steroids • Oral prednisolone: 40–60 mg daily • Systemic steroids should be given for seven days for adults and three to five days for

38. Magnesium sulphate • A single dose of IV magnesium sulphate (1.2–2 gm IV infusion over 20 mins) is safe and effective • Routine use of IV magnesium sulphate in patients with acute asthma presenting to emergency department is not recommended. • Its use should be limited to those with sever exacerbation who fail to respond to treatment after an hour

39. Intravenous aminophylline • In acute asthma, the use of intravenous aminophylline did not result in any additional bronchodilation compared to standard care with B2-agonists

40. Antibiotics • Viral infection is the usual cause of asthma exacerbation • The role of bacterial infection has been probably overestimated, and routine use of antibiotics is strongly discouraged • They should be used when there is associated pneumonia or bacterial bronchitis

41. Initial Management of Acute Asthma

42. If there is an adequate response

43. If there is a partial response

44. If there is a poor response

45. Referral to a specialist center • Status asthmatics • Deteriorating PEF • Persisting or worsening hypoxia • Hypercapnea, respiratory acidosis (pH <7.3) • Severe exhaustion • Increase work of breathing • Drowsiness • Confusion • Coma • Respiratory arrest

46. Criteria for admission • Patients whose peak flow is ≥ 60% best or predicted one hour after initial treatment can be discharged from the emergency department • Criteria for admission: • Any feature of a life threatening, near fatal attack • Any feature of a severe attack that persists after initial treatment. • unless any of the following is present: • still suffering from significant symptoms • previous history of near fatal or brittle asthma • concerns about compliance and pregnancy

47. Asthma in children < 5 years • No tests can diagnose asthma with certainty. • Lung function testing is not very helpful • CXR may help to exclude structural abnormalities of the airway. • A trial of treatment with short-acting bronchodilators and inhaled corticosteroids (ICS) for at least 8 to 12 weeks may provide some guidance as to the presence of asthma.

48. Acute asthma in children < 5 years • Immediate medical attention should be taken in case of children less than two year who had a history of poor response to three doses of SABA within 1–2 hours, saturation less than 92%, or the child is acutely distressed. • In this age group, the risk of fatigue, respiratory compromise and dehydration is considerable