Asthma in Egypt 2007 PowerPoint Presentation

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1 بسم الله الرحمن الرحيمBronchial AsthmaSuggested Guidelines in Egypt Prof. Mohammad Rashad Professor of Pediatrics Benha University

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Asthma is the commonest chronic disease in children. Affects about quarter billion (235 million) persons all over the world. High prevalences were recorded in advanced countries but, most deaths occur in the developing countries. (WHO: Asthma Fact Sheet N°307 May 2011) In some areas of Egypt, asthma is the commonest cause of hospital admission. (GINA; 2004)

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3 Annual costs in USA: Direct health care: > $ 10 billion Indirect health care: $ 8 billion Prescription drugs: $ 5 billion = 23 billion $ / year = 136 مليـــــار جنيه كل سنة American Academy of Allergy, Asthma & Immunology; 2008

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In Egypt We have: Diagnostic problems. Therapeutic problems. What to do? 4

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5 Asthma Phenotypes

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8 Asthma can be classified into: Atopic (extrinsic): symptoms are precipitated by allergens. Non-atopic (intrinsic): symptoms are not precipitated by allergens. Kumar, et al.: (2010); Robbins and Cotran Pathologic Basis of Disease (8th ed.). Saunders. p. 688.

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10 Copyright © 2011 by the European Respiratory Society Atopic Non-atopic

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Asthma Predictive Index 12

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* Children <3 years with* >4 wheezing episodes in the last year that*lasted >1day with sleep disturbance And One Major criterion: Parent with asthma. Atopic dermatitis. Sensitization to an aeroallergen. Two minor criteria: Wheezing apart from colds. Aeosinophilia > 4%. Food allergies. 13 National Heart, Lung and Blood Institute (NHLBI) 2007 If +ve , then 76% likelihood of asthma after 6 y’s of age If –ve , then 97% likelihood of not developing asthma Or

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14 Asthma Diagnosis Is it Asthma?? Clinical history & examination. Pulmonary functions e.g. PEFR. What phenotype?? Clinical history. Laboratory tests e.g. S.IgE; Total + specific.

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15 Asthma Symptoms Cough. Wheeze. Difficult breathing. Chest tightness. Recurrent. More at night, awakening the patient. Responsive to anti-asthma therapy. (GINA Pocket; 2010a) Patient’s colds “go to the chest” or take more than 10 days to clear up.

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16 Other Symptoms: Symptoms on exposure to aerosols, smoke, drugs, cold air, exercise, emotions or respiratory infection. Atopic symptoms: Symptoms on exposure to animals, birds, cockroaches, dust mites, pollens, Seasonal symptoms. Past history of other atopy. Family history of any atopy.

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17 Video 1 Symptoms

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18 Asthma Signs Airflow limitation Air trapping Increased chest dimensions Decreased chest movements Hyperresonance Prolonged expiration Expiratory + inspiratory rhonchi Ptosed liver & spleen

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19 Pulmonary Function Tests

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20 Peak Expiratory Flow (PEF) Compared to the patient’s previous best, using his/her own peak flow meter. Diurnal variation of >20% (with twice-daily readings, >10%). or Improvement of >20% after inhalation of a bronchodilator suggests asthma. (GINA Pocket, 2010a)

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21 Spirometry It is the preferred method to measures the airflow limitation and its severity to establish the diagnosis of asthma. An increase in FEV1 of >12% after inhalation of a bronchodilator indicates reversible airflow limitation consistent with asthma. (GINA Pocket, 2010a)

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23 Laboratory Tests Confirm the diagnosis & detect the triggers. Serum IgE: Total & Specific. Skin test: (GINA Pocket, 2010a) Phagocytosis inhibition test: Specific (Soliman & Attia , 2007)

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24 Diagnostic Challenges Children <5 years: The clinical picture & Serum IgE (total + specific to inhalants) are very helpful. Cough varient asthma: Pulmonary function tests and Provocation tests are important. Exercise induced asthma: Exercise test with an 8-minit running protocol can establish a firm diagnosis. (GINA Pocket, 2010a)

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25 Asthma Management Environmental control. Pharmacotherapy. - During attacks (Relievers). - Between attacks (Controllers). Immunotherapy (Desensitization). Follow up. Parent education.

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27 2006 Level of Asthma Control

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28 Therapeutic ProblemsIn Egypt Inhalation Phobia. Steroid Phobia. Antibiotic controversy. Antipyretic controversy.

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29 (GINA 2010)

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30 For newly diagnosed patients or not on medication, treatment should start at Step 2. If the patient is very symptomatic, start at Step 3.

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Asthma Managementfor Children 5 Years and Younger (GINA Ped . 2009)

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32 Antibiotic Controversy (Rashad et al., 2009)

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33 Antipyretic Phobia Watch Video 2 (Paracetamol)

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34 Follow Up Review the treatment every 3 months. * If control is achieved, Step Down i.e. gradually reduce the treatment. * If daily and/or increasing use of inhaled β2 agonists, Step Up to more long-term control therapy.

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38 Promising new drugs Anti-CD23 antibody [ IDEC-152 ]: Influences IgE production. J Allergy Clin Immunol;2003;112:563-570. Omalizumab [ Xolair ]: Binds to free IgE. PEDIATRICS Vol. 108 No. 2 August 2001, p. e36.

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40 Cytokine inhibitors: - Anti-interleukin-4. - Anti-interleukin-5. Cytokine-based therapy. - Interleukin-12. CHEST 2002: 68th Annual Scientific Assembly of the American College of Chest Physicians November 2 - 7, 2002, San Diego, California

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41 الحمد للـــه