How Do We Achieve Optimal Asthma Control? Role of Nebulised steroids in Management of Asthma BY MAYSA SHARAF ELDIN PROFESSOR OF PULMONARY MEDICINE CAIRO UNIVERISITY
Dec 30, 2015
How Do We Achieve Optimal Asthma Control?
Role of Nebulised steroids in Management of Asthma
BY
MAYSA SHARAF ELDINPROFESSOR OF PULMONARY
MEDICINE
CAIRO UNIVERISITY
• Why do we care about asthma
control?
• What do we mean by asthma
control?
• Inhalation Therapy
Prof. Maysa Sharaf El Din
Why do we care about asthma control?
Prof. Maysa Sharaf El Din
Burden of Asthma
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
GINA 2010
Burden of Asthma
Health care expenditures very high Developed economies might expect to spend
1-2 percent of total health care expenditures on asthma.
Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Health care expenditures very high Developed economies might expect to spend
1-2 percent of total health care expenditures on asthma.
Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
GINA 2011
What do we mean by asthma control?
Prof. Maysa Sharaf El Din
Clinical Control of Asthma
No (or minimal)* daytime symptoms
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue medication
Normal lung function
No exacerbations
No emergency visits
No treatment-related adverse eventsAll of the above sustained for at least 7 out of 8 weeks* Minimal = twice or less per week
GINA 2011
Clinical Control of Asthma
No (or minimal)* daytime symptoms
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue medication
Normal lung function
No exacerbations
No emergency visits
No treatment-related adverse eventsAll of the above sustained for at least 7 out of 8 weeks* Minimal = twice or less per week
How many of our patients
actually achieve this?
GINA 2011
Factors Affecting Inhaled Drug Delivery and Deposition
- Geometry of the respiratory tract
- Inspiratory flow
- Time in the airway (breath hold)
- Particle diameter and density
Prof. Maysa Sharaf El Din
What we know: Particle Size
2 – 5 Upper / central airways
Clinical effect
Subsequent absorption from lung
< 2Peripheral
airways / alveoli
Some local clinical effect
High systemic
absorption
> 5
Particle size (microns)
Regional deposition
Efficacy Safety
Mouth / oesophageal
region
No clinical effect
Absorption from GIT if swallowed
All inhaled methods ( MDI & DPI )• Compliance, adequate technique• 75% - 93% of patients on traditional
press-and-breathe inhalers use
improper technique• Even after retraining, up to 50% revert
to incorrect techniques
Prof. Maysa Sharaf El Din
Factors affecting drug delivery with nebulised therapy
• 1. Device-related factors• Airflow• Droplet size• Nebulisation time and volume
• 2. Drug-related factors• The shape and size of drug particles• water solubility• The viscosity and surface tension of the formulation
• 3. Patient-related factors• Breathing patterns• inspiratory flow rate
Prof. Maysa Sharaf El Din
Clinical Profile: Who Are the Ideal Patients for Nebulized Therapy?
• Patients inadequately controlled and
unable to achieve symptomatic relief with
MDI/DPI therapy
• Patients with cognitive impairment
• Patients unable to use MDI/DPI devices
appropriately (eg, patients with arthritis,
peripheral neuropathy)
• Home health care patientsProf. Maysa Sharaf El Din
Advantages of Nebulizers
• Any age • Easy to teach and use• Patient coordination not required• preferred inhalation device in infants
and for acute Rx in ERs and hospital• High drug doses possible • Can be used with supplemental oxygen• No propellant required
Prof. Maysa Sharaf El Din
Types of nebulizers
1. Jet nebulizer Driven by compressed air. The smaller droplets leave the
nebuliser as a fine mist.The larger droplets fall by gravity and returned to the reservoir
2. Ultrasonic nebulizer The aerosol is created by a rapid vibrations. Ultrasonic nebulisers should not be used to deliver
suspensions
3. Mesh nebulizer Liquid or drug suspension is pushed through a fine static
mesh. There is no recycling into the reservoir of inappropriately sized droplets
Prof. Maysa Sharaf El Din
Jet and Ultrasonic Nebulizers
JET• Cools during operation• Small aerosol particle size• Less expensive• More noise
ULTRASONIC• Heats up during operation• Larger aerosol particle• More expensive• Less noise
Prof. Maysa Sharaf El Din
New Generation Nebulizers:
Vibrating Mesh or Plate Nebulizers
Pari e-flowMicroAIR U22www.omron-healthcare.com
www.aerogen.com/theproducts.htm
www.eflow.pari.de/200/index.html
Advantages of New Vibrating Mesh or Plate Nebulizers
• Simple, compact, silent
• Do not require propellants or a compressor system
• Portable, battery operated, designed for use by
ambulatory patients
• High fine particle fraction
– Highly efficient delivery of aerosols to lower
respiratory tract
• Only negligible volume of drug solution left in
device
• Low aerosol velocity throat deposition
Prof. Maysa Sharaf El Din
Limitations of Vibrating Plate/Mesh Devices
• Cost higher than jet nebulizers
• Need for regular cleaning to prevent blockage of
minute apertures with drug particles (especially
with suspensions)
• Batteries need to be replaced periodically
• Need to reduce drug dose/volume of solution
because of higher efficiency of drug delivery in
order to prevent “overdosing”
Prof. Maysa Sharaf El Din
Adaptive Aerosol Delivery (AAD)“Smart nebulizers”
• Principle: delivery of precise and reproducible amounts of drug – adapted to the breathing
pattern– during part of inspiration
• Benefit
- improvement of efficacy and compliance Prodose AAD System
Hoda is 45 years old female patient.
She has long-term asthma. She is known case of Diabetes. Her
current treatment is ICS+LABA plus SABA when needed. She has
symptoms which impair ability to sleep and perform daily
activities with persistent cough, wheezing and chest tightness
several days each week
Q: Is her asthma
1. Well controlled
2. Partially uncontrolled
3. Uncontrolled
Hoda is 45 years old female patient.
She has long-term asthma. She is known case of Diabetes. Her
current treatment is ICS+LABA plus SABA when needed. She has
symptoms which impair ability to sleep and perform daily
activities with persistent cough, wheezing and chest tightness
several days each week
Q: Is her asthma
1. Well controlled
2. Partially uncontrolled
3. Uncontrolled
Levels of Asthma Control
Characteristic Controlled(All of the following)
Partly controlled(Any present in any
week)Uncontrolled
Daytime symptomsNone (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities
None Any
Nocturnal symptoms / awakening
None Any
Need for rescue / “reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Exacerbation None One or more / year 1 in any week
GINA 2011
What is your further management?
1. Increase dose of ICS
2. Add Theophylline
3. Start Antibiotics
4. Oral steroids
What is your further management?
1. Increase dose of ICS
2. Add Theophylline
3. Start Antibiotics
4. Oral steroids
(Evidence A) 2009
She increased her inhaled steroid from 2 to 4 inhalations twice daily, but noted no improvement. She found herself needing to use her ventolin inhaler 4-5 times per day. After a sleepless night of cough and chest congestion, she sought help at her local hospital
In the ED she appeared in moderate distress. She had laboured breathing at 28 breaths/min, with a markedly prolonged expiratory phase. She was using her accessory muscles of respiration. Her blood pressure was 120/70 mm Hg with 20 mm Hg paradoxical pulse. Her heart rate was 112 beats/minute. Chest examination revealed musical inspiratory and expiratory wheezes throughout all lung fields.
1. Nebulised steroids
2. Oxygen therapy
3. IV Theophylline
4. Nebulized SAMA
5. All of above
6. None of the above
What is the required treatment for her in hospital?
1. Nebulised steroids
2. Oxygen therapy
3. IV Theophylline
4. Nebulized SAMA
5. All of above
6. None of the above
What is the required treatment for her in hospital?
1. Oral steroids
2. Nebulized steroids
3. ICS
4. No steroids
Over the next 2-3 days she progressively improved, and is now ready for home
discharge.To prevent relapse after hospital or ER
discharge , would you recommend :
1. Oral steroids
2. Nebulized steroids
3. ICS
4. No steroids
Over the next 2-3 days she progressively improved, and is now ready for discharge
home.To prevent relapse after hospital or ER
discharge , would you recommend :
1. Near-fatal asthma
2. Life threatening asthma
3. Acute severe asthma
4. Moderate asthma exacerbation
5. Brittle asthma
How do you classify her acute asthma?
How do you classify her acute asthma?
1. Near-fatal asthma
2. Life threatening asthma
3. Acute severe asthma
4. Moderate asthma exacerbation
5. Brittle asthma
Levels of severity of acute asthma
• Life threatening asthma : altered conscious level, Exhaustion, Arrhythmia Hypotension, Cyanosis, Silent chest, Poor respiratory effort.
• Near-fatal asthma : Hypoxemia SpO2 <92%, PaO2<60 mmHg and/or Raised PaCO2 requiring MV with raised inflation pressures.
• Acute Severe Asthma : Any one of: unable to complete 1 sentences in 1 breath, respiratory rate ≥25/min, heart rate ≥110/min, PEF 33-50% best or predicted
• Moderate asthma exacerbation: Increasing symptoms, PEF >50-75% best or predicted no features of acute severe asthma
• Brittle Asthma : • Type 1: wide PEF variability despite intense therapy (>40%
diurnal variation for >50% of time over a period >150 days)• Type 2: sudden severe attacks on a background of apparently
well controlled asthma
British Thoracic Society Guidelines (BTS) 2009
NOTES
Prof. Maysa Sharaf El Din
Instructions for correct use of Nebulizer:1. Budisonide should be administered via Jet Nebulizer with a
mouthpiece or suitable facemask. Ultrasonic nebulizers are not suitable & therefore dis-recommended.
2.Nebulizer should be connected to an air compressor with an adequate airflow (5 – 8 l/min).
3.Fill volume should be 2 – 4 ml.
Instructions for correct use of Nebulizer:
4. Budisonide Nebulising Suspension can be mixed with 0.9% saline & nebulizer solutions of: - Terbutaline- Salbutamol- Sodium Cromoglycate - Ipratropium - Fenoterol- Acetylcysteine
Management of Acute Asthma (Evidence-Based)• Regular bronchodilators including ipratropium
bromide. (Level A).• Oxygen (Controlled) (Level A).• Corticosteroids (Level A).• No role for routine antibiotics, rehydration
(Level A).• Magnesium for more severe attacks (Level A).
Prof. Maysa Sharaf El Din
Cell Nucleus
GC-receptor
BudesonideBudesonide
Budesonide estersINACTIVE!
lipolysisesterifi-cation
Reactivated Esterification of budesonide
Miller-Larsson et al. 1998 and Wieslander et al. 1997
Prolonged duration of
action
Increasedairway
selectivity