Asma: Guía de Diagnóstico y Tratamiento PDF

# Asma ## Universidad de Monterrey - Profesor Academia Inmunología Clínica Dr. David Eugenio Román Cañamar - Alergia e Inmunología Clínica - 20 agosto 2024 ## Introducción - Enfermedad inflamatoria crónica más frecuente de las vías respiratorias - Heterogénea - Desde fisiopatología y proceso...

# Asma ## Universidad de Monterrey - Profesor Academia Inmunología Clínica Dr. David Eugenio Román Cañamar - Alergia e Inmunología Clínica - 20 agosto 2024 ## Introducción - Enfermedad inflamatoria crónica más frecuente de las vías respiratorias - Heterogénea - Desde fisiopatología y proceso inflamatorio y su presentación clínica - Alto porcentaje de tratamientos erróneos - Carga emocional y economía para el paciente y familiares. - Por limitaciones que causa en la vida / nunca está bien controlado ## Definición - Síndrome clínico complejo de las vías aéreas bajas | | | | | ---------- | ------------------------------------- | ------------------ | | Inflamación | Hiperreatividad bronquial | Obstrucción | | | *No necesariamente es asma pero siempre están presentes en asma* | | | | *Componentes fisiopatológicos* | | | | *bhay casos en los que no es variade y es fijo* | | | | | *Intensidad* | | | | *Frecuencia* | | | | *Presentación* | | | | *Manifestación* | ## Epidemiología - Causa común de consulta en primer nivel de atención - 300 millones de personas en el mundo = 1-18% de la población - Mayor en países desarrollados - 10 de cada 100 niños tienen asma - 250,000 muertes /año ## Términos - Asma: Síndrome clínico caracterizado por disnea, sibilancias, tos crónica y dolor torácico que es variable en intensidad y frecuencia - No necesariamente es asma - Hiperreactividad bronquial: Aumento de la sensibilidad a estímulos broncoconstrictores ## Factores asociados | | | | | ---------------------------- | --------------------- | --------------------- | | Intrauterine or postnatal | Asthma development | Asthma exacerbation | | | Genetics | Genetics | | | Allergens | HRV and other viruses | | | *Infecciones virales especialmente el virus sincirial respiratorio* | | | | RSV and HRV | | | | Air pollution | PM, VOCs, NO2, O3, and TRAP | | | | High-level air pollution | | | | Tobacco smoke (ETS) | | | | Obesity | ## Fenotipos - Alérgica eosinofílica - Lo IgE, más comun - IgE - B cells - IL4 / 13 - Dendritic cell - IL5 T2 - Eosinophil - PGD - PGD - No Alérgica eosinofílica - No hay sensibilización previa, no hay IgE, IL5 involucrada - Hipersensibilidad tipo 4 - Paucigranulocítica - Diferentes infiltrados / no hay mucha info - Neutrofílica - No hay alergia, IgE o eosinófilos/pacientes con asma asociados a tabaquismo, obesidad, reflujo / puede llegar a EPO - Hipersensibilidad tipo 4/normalmente son dependientes de cel ## Fisiopatología - Alérgica - Daño a la mucosa de manera repetitiva - Entrada de alergenos y switch inmunológico de Th2 - Genera proceso inflamatorio - Como no cede inflamación, llegan miioribroblastos y fibrosis de la vía vespiratoria y puede llegar a EPOC ## Relación entre el espesor de la pared bronquial y el calibre de la vía aérea - Normal - Chronic asthma - Infiltrado mayor, hiperplasia de las glandulas productoras de moco, daño en los cilios, hiperplasia en la muscular, vía aérea fija ## Características clínicas - Normal airway - Asthmatic airway - Wall inflamed and thickened - Nacen de los mecanismos fisiopatológicos - Asthmatic airway during attack - Air trapped in alveoli - Tightened smooth muscles - Tos - No se necesitan la presencia de los sintomas pora decir que tiene asma - Sibilancias - Disnea - Dolor torácico - Piedra angular - Inflamación ## Cuadro clínico - No tienen que estar todos presentes / 2+ sintomas - Variable - Tos crónica - Tos seca - Dolor torácico - Espalda, garganta baja - Nace desde la contracción muscular de los bronquios - Relacionado a la disnea y dificultad respiratoria - Sibilancias - Son espiratorios / sacar el aire - Disnea ## Cuadro clínico - Síntomas asociados - Fatiga crónica - Despertares nocturnos - Evitan hacer actividades físicas - Se cansan antes que otros niños - Niños ## Exploración física | | | | ------ | ---------------------------------------------------------- | | Normal | *Saturación O2* **Frecuencia respiratoria** *Claro pulmonar* | | Anormal | *Cualquier sintoma asociado a la disnea, broncoconstricción, etc* | | | *Desaturación O2* **Cianosis** **Taquipnea** **Somnolencia** | | | *Dificultad de habla* **Dificultad respiratoria** **Músculos accesorios** | | | *Sibilancias* | ## Factores desencadenantes - Ejercicio - Solo tiene la crisis si hay un esfuerzo físico - Risa - Esfuerzo respiratorio bronquial - Frio - Humo / contaminantes de aire - Estrés - Alergenos - Procesos virales e infecciosos - Los mismos procesos estimulan las crisis - Niños que únicamente tienen cuadro en procesos febriles - Mascotas - No usar medicamentos de control y solo de rescate. - Usar medicamento de control como de rescate. ## Diagnóstico - Historia clínica - Exploración física - Estudios complementarios - Espirometría - Flujo espiratorio máximo (FEM) - Detección de IgE específica - Prueba de reto ## Diagnóstico - Historia clínica - Presencia de 2 o más síntomas - Un sintoma más alteración de la espirometria - Variable - Intensidad - Frecuencia - Asociado a factores desencadenantes ## Diagnóstico - Espirometría = Limitación del flujo aéreo - Te dice si es vía aérea fija o reversible ## Valores en Asma - FEV1: < 80% - Volumen espiratorio forzado - CVF: ≤ Normal - Flujo total pulmonar / capacidad vital forzada - FEV1/CVF: - < 80% adultos - < 90% niños - FEV1 PBD: - Post broncodliatador - > 12% - > 200 ml ## Diagnóstico - FEM = Limitación del flujo aéreo ## Diagnóstico - Detección de IgE específica - Asma alérgica o no - Pruebas cutáneas - IgEs suero - Ensayo Inmuno-enzimático - Positivo: ≥ 0.35 KU/L ## Diagnóstico - Cuadro 7-3 Diagnóstico del asma en adultos - Síntomas de disnea episódica, sibilancias, tos, opresión torácica, expectoración (uno o más) - Aumento del VEMS tras un broncodilatador o después de un ciclo de tratamiento controlador ≥ 12% (y un mínimo de ≥200 ml) - Aumento del FEM tras un broncodilatador o después de un ciclo de tratamiento controlador de 60 l/min (mínimo ≥20%) o un incremento ≥20% basado en múltiples mediciones diarias - CP20 con metacolina <4 mg/ml (4-16mg/ml es un valor limite) - Disminución del VEMS tras provocacion con ejercicio ≥10-15% ## Diagnóstico diferencial - Age: 12-39 years - Sneezing, itching, blocked nose, throat-clearing - Dyspnea, inspiratory wheezing (stridor) - Dizziness, paresthesia, sighing - Productive cough, recurrent infections - Excessive cough and mucus production - Cardiac murmurs - Shortness of breath, family history of early emphysema - Sudden onset of symptoms - Age: 40+ years - Dyspnea, inspiratory wheezing (stridor) - Dizziness, paresthesia, sighing - Cough, sputum, dyspnea on exertion, smoking or noxious exposure - Productive cough, recurrent infections - Dyspnea with exertion, noctumal symptoms - Treatment with angiotensin converting enzyme (ACE) inhibitor - Dyspnea with exertion, non-productive cough, finger clubbing - Sudden onset of dyspnea, chest pain - Dyspnea, unresponsive to bronchodilators - All ages - Chronic cough, hemoptysis, dyspnea; and/or fatigue, fever, (night) sweats, anorexia, weight loss | | | | --------------------- | ------------------------------------------------------------------------------------------------------------------------------ | | 12-39 years | Chronic upper airway cough syndrome, Inducible laryngeal obstruction, Hyperventilation, dysfunctional breathing, Bronchiectasis, Cystic fibrosis, Congenital heart disease, Alpha-antitrypsin deficiency, Inhaled foreign body | | 40+ years | Inducible laryngeal obstruction, Hyperventilation, dysfunctional breathing, COPD, Bronc hiectasis, Cardiac failure, Medication-related cough, Parenchymal lung disease, Pulmonary embolism | | All ages | Central airway obstruction, Tuberculosis | ## Gravedad - Factores de riesgo - Having uncontrolled asthma symptoms is an important risk factor for exacerbations. - Medications: high SABA use (with increased mortality if >1 x 200-dose canister/month) - inadequate ICS, not prescribed ICS, poor adherence, incorrect inhaler technique - Comorbidities: obesity, chronic rhinosinusitis, GERD, confirmed food allergy, pregnancy - Exposures: smoking, allergen exposure if sensitized, air pollution - Context major psychological or socioeconomic problems - Lung function: low FEV1, especially <60% predicted, high BD reversibility - Other tests in patients with Type 2 inflammation: blood eosinophils, elevated FeNO - In adults with allergic asthma taking ICS - Other major independent risk factors for flare-ups (exacerbations) - Ever intubated or in intensive care unit for asthma - ≥1 severe exacerbation in last 12 months ## Gravedad | | | | | | | ------------------ | ---------------------- | ------------------- | ------------------- | ------------------- | | **Intermitente** | **Persistente (leve)** | **Persistente moderada** | **Persistente grave** | | | Síntomas diurnos | No (2 veces o menos a la semana) | Síntomas a diario | Síntomas continuos (varias veces al día) | | | Medicación de alivio | No (2 veces o menos /semana) | Más de 2 veces a la semanqa pero no a diario | Todos los días | Varias veces al día | | Síntomas nocturnos | No más de 2 veces al mes | Más de 2 veces al mes | Más de una vez a la semana | Frecuentes | | Limitación de la actividad | Ninguna | Algo | Bastante | Mucha | | Función pulmonar (FEV1 o PEF) % teórico | > 80% | > 80% | > 60% - < 80% | ≤ 60% | | Exacerbaciones | Ninguna | Una o ninguna al año | Dos o más al año | Dos o más al año | - FEV1: volumen espiratorio forzado en el primer segundo; PEF: flujo espiratorio máximo. ## Gravedad - Factores de riesgo para mortalidad - Antecedentes de asma - Exacerbaciones graves previas (p. ej., intubación o ingreso en UCI por asma) - Dos o más hospitalizaciones por asma en el año anterior - Tres o más visitas a urgencias por asma en el año anterior - Hospitalización o visitas a urgencias por asma en el mes anterior - Uso de más de dos envases de SABA al mes - Dificultad para percibir los sintomas de asma o la gravedad de las exacerbaciones - Otros factores de riesgo: falta de plan de acción por escrito contra el asma, sensibilidad a Alternaria - Antecedentes sociales - Bajo estatus socioeconómico o residencia en zona urbana degradada - Consumo de drogas - Problemas psicosociales graves - Enfermedades concurrentes - Enfermedad cardiovascular - Otra enfermedad pulmonar crónica - Enfermedad psiquiátrica crónica ## Evaluación del control - Box 2-2. GINA assessment of asthma control in adults, adolescents and children 6-11 years - A. Asthma symptom control - In the past 4 weeks, has the patient had: - Daytime asthma symptoms more than twice/week? - Any night waking due to asthma? - No cuentan otras condiciones, específicamente por asma - SABA reliever for symptoms more than twice/week? - > medicación de rescate - Any activity limitation due to asthma? | | | | | | -------------------------- | ----------- | ---------- | ----------- | | **Level of asthma symptom control** | **Well controlled** | **Partly controlled** | **Uncontrolled** | | **In the past 4 weeks, has the patient had:** | | | | | Daytime asthma symptoms more than twice/week? | Yes No | Yes No | Yes No | | Any night waking due to asthma? | Yes No | Yes No | Yes No | | SABA reliever for symptoms more than twice/week? | Yes No | Yes No | Yes No | | Any activity limitation due to asthma? | Yes No | Yes No | Yes No | ## Tratamiento - Farmacológico - NO - Desinflama - Controla - Previene - Rescate - Broncodilatador - SI - Desinflama - Controla - Previene - Control - Lleva proceso desinflamatorio - No farmacológico - Solo si hay síntomas - Broncoespasmo - SABA - Dura 4-6 horas - Salbutamol - Ipatropio - Haya o no síntomas - Corticoesteroide inhalado - CEI - CEI/LABA - Broncodilatador de acción larga, dura ~12 horas ## Tratamiento - Starting treatment in adults and adolescents 12+ years with a diagnosis of asthma - First Assess: - Confirmation of diagnosis - Symptom control & modifiable risk factors (including lung function) - Comorbidities - Inhaler technique & adherence - Patient preferences & goals - IF: - Daily symptoms, waking at night once a week or more and low lung function? - START WITH (preferred): - Track 1 - Medium dose ICS-formoterol maintenance and reliever (MART) - Track 2 - Medium/high dose ICS-LABA + as-needed SABA - NO - Symptoms most days, or waking at night once a week or more? - YES - Low dose ICS-formoterol maintenance and reliever (MART) - Low dose ICS-LABA + as-needed SABA - NO - Symptoms twice a month or more? - YES - As-needed low dose ICS-formoterol - Low dose ICS + as-needed SABA - NO - As-needed low dose ICS-formoterol - Take low dose ICS whenever SABA is taken - STEP 4 - STEP 3 - STEP 2 - STEP 1 - Short course OCS may also be needed for patients presenting with severely uncontrolled asthma - As-needed ICS-formoterol is preferred if the patient is likely to be poorly adherent with daily ICS - ICS-containing therapy is recommended even if symptoms are infrequent, as it reduces the risk of severe exacerbations and need for OCS - As-needed ICS-formoterol is preferred if the patient is likely to be poorly adherent with daily ICS - ICS-containing therapy is recommended even if symptoms are infrequent, as it reduces the risk of severe exacerbations and need for OCS ## Tratamiento - Starting treatment in adults and adolescents with a diagnosis of asthma - Track 1 is preferred if the patient is likely to be poorly adherent with daily controller ICS-containing therapy is recommended even if symptoms are infrequent, as it reduces the risk of severe exacerbations and need for OCS. - Suben de step en 2-4 semanas, bajan de step en 3+ meses - Evaluar primero - First Assess: - Confirm diagnosis - Symptom control & modifiable risk factors, including lung function - Comorbidities - Inhaler technique and adherence - Patient preferences and goals - Preguntar - Sintomas >2 veces pisoe mana - Despertarse en la noche - SABA 2 veces pisemana - Afecta actividades - Primer mundo - START HERE IF: - CONTROLLER and PREFERRED RELIEVER (Track 1): Using ICS-formoterol as reliever reduces risk of exacerbations compared with using a SABA reliever - Tercer mundo - START HERE IF: - STEPS 1 (Paciente más asintomático) - As-needed low dose ICS-formoterol - Solo rescate - LABA dura ~12 horas - Daily symptoms or waking with asthma once a week or more and low lung function - Paciente sique como no/parcialmente controlado Refer for phenotypic assessment ± anti-IgE, anti-IL5/5R, anti-IL4R - Consider high dose ICS-formoterol - Controlador adicional/controlado - Symptoms most days, or waking with a sthma once a week or more - Medium dose maintenance ICS-formoterol - Symptoms less than 4-5 days a week - Lowdose maintenance ICS-formoterol - Symptoms less than twice a month - Take ICS whenever SABA taken - Symptoms twice a month or more, but less than 4-5 days a week - Low dose maintenance ICS + LABA - Symptoms most days, or waking with asthma once a week or more - Medium/high dose maintenance ICS-LABA - Add-on LAMA - Refer for phenotypic assessment - Consider high dose ICS-LABA - Daily symptoms, or waking with asthma once a week or more, and low lung function - Short course OCS may also be needed for patients presenting with severely uncontrolled asthma - Add-on LAMA - Consider high dose ICS-LABA - Symptoms most days, or waking with asthma once a week or more - Short course OCS may also be needed for patients presenting with severely uncontrolled asthma - Add-on LAMA - Consider high dose ICS-LABA - Symptoms least than 4-5 days a week - Controller and ALTERNATIVE RELIEVER (Track 2): Before considering a regimen with SABA reliever, check if the patient is likely to be adherent with daily controller therapy - RELIEVER - As-needed low-dose ICS-formoterol - CEI - Cel + salmeterol inicio de acción lento (6-8hvs)/no sirve de rescate - CEL+ Formoterol - Dinicio de acción rápido (5-10min) - Short course OCS may also be needed for patients presenting with severely uncontrolled asthma - RELIEVER - As-needed short-acting ß2-agonist - CEI dosis media & tiempo prolongado - Cel dosis alta - Lo ej. candidiasis oral ## Tratamiento - Starting treatment in adults and adolescents 12+ years and older - Inhaled corticosteroid - Beclometasone dipropionate (PMDI, standard particle, HFA) - Beclometasone dipropionate (pMDI, extrafine particle*, HFA) - Budesonide (DPI) - Ciclesonide (pMDI, extrafine particle*, HFA) - Fluticasone furoate (DPI) - Fluticasone propionate (DPI) - Fluticasone propionate (pMDI, standard particle, HFA) - Mometasone furoate (DPI) - Mometasone furoate (pMDI, standard particle, HFA) | | | | | | | ------------------ | ------------------------- | ---- | ------ | ------ | | **Inhaled corticosteroid** | **Low** | **Medium** | **High** | | | Beclometasone dipropionate (PMDI, standard particle, HFA) | 200-500 | >500-1000 | >1000 | | | Beclometasone dipropionate (pMDI, extrafine particle*, HFA) | 100-200 | >200-400 | >400 | | | Budesonide (DPI) | 100-200 | >400-800 | >800 | | | Ciclesonide (pMDI, extrafine particle*, HFA) | 80-160 | >160-320 | >320 | | | Fluticasone furoate (DPI) | - | 100 | 200 | | | Fluticasone propionate (DPI) | 100-250 | >250-500 | >500 | | | Fluticasone propionate (pMDI, standard particle, HFA) | 100-250 | >250-500 | >500 | | | Mometasone furoate (DPI) | - | 200 | 400 | | | Mometasone furoate (pMDI, standard particle, HFA) | - | 200-400 | >400 | | ## Tratamiento - Inmunológico → para alérgico eosinofilico ## Tratamiento - Crisis de asma - Sibilancias - Accesos de tos - Disnea - Dolor torácico | | | | ----------------------- | -------------------------------------- | | RESCATE | *Terapia MART* | | | *Broncodilatador de acción rápida (SABA)* | ## Referir a especialista - Lo moderadas-graves / comorbilidades / sospecha de componente alérgico ## Asma en niños (6-12 años) - Síntomas atípicos - Independientes de infecciones virales - Tos variante de asma - Evitan hacer actividades físicas - Se cansan antes que otros niños - Espirometría > 6 años o técnica adecuada ## Asma en niños - Starting treatment in children 6-11 years with a diagnosis of asthma. - Assess: - Confirmation of diagnosis - Symptom control & modifiable risk factors (including lung function) - Comorbidities - Inhaler technique & adherence - Child and parent preferences and goals - START HERE IF: - Symptoms less than twice a month - Symptoms twice a month or more, but less than daily - Symptoms most days, or waking with asthma once a week we or more - Symptoms most days, or waking with asthma once a week or more, and low lung function - Short course OCS may also be needed for patents presenting with severely uncontrolled asthuma - PREFERRED CONTROLLER to prevent exacerbations and control symptoms - STEP 1 - Low dose ICS taken whenever SABA taken - STEP 2 - Daily low dose inhaled corticosteroid (ICS) - ver tabla de dosis de ICS para niños) - STEP 3 - Lowdose ICS-LABA, OR medium dose ICS, OR very low dose ICS-formoterol maintenance and reliever (MART) - Esteroide combinado/LABA - STEP 4 - Medium dose ICS-LABA, OR low dose ICS-formoterol maintenance and reliever therapy (MART). Refer for expert advice - Esteroide combinado - Add tiotropium or add LTRA - STEP 5 - Refer for phenotypic assessment - + higher dose ICS-LABA or add-on therapy, e.g. anti-lgE - Add-on anti-IL5, or add-on low dose OCS but consider side-effects - RELIEVER - As-needed short-acting B₂-agonist (or low dose ICS-formoterol reliever for MART as above) - "Very low dose: BUD-FORM 100/6 mcg" - "Low dose: BUD-FORM 200/6 mcg (metered doses). - Other controller options - Daily leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken ## Tratamiento - Suggested initial controller treatment in children 6-11 years with a diagnosis of asthma. - First Assess - Confirmation of diagnosis - IF - Symptoms most days, waking at night ≥ once a week and low lung function? - START WITH - YES - Medium dose ICS-LABA or low dose MART™. Refer for expert advice - NO - Symptoms most days,or waking at night ≥ once a week? - YES - Low dose ICS-LABA or medium dose ICS or very low dose MART*T - NO - Symptoms twice a month or more? - YES - Daily low dose ICS - NO - Take ICS whenever SABA taken - STEP 4 - STEP 3 - STEP 2 - STEP 1 - Short course OCS may also be needed for patients presenting with severely uncontrolled asthma - *Low dose: BUD-FORM 200/6 mcg: “Very low dose: BUD-FORM 100/6 mcg (metered doses) - MART = maintenance and reliever therapy (ICS-formoterol as both maintenance and reliever) ## Tratamiento - Children 6-11 years - see notes above (for children 5 years and younger, see Box 6-6, p.153) - Beclometasone dipropionate (pMDI, standard particle, HFA) - Beclometasone dipropionate (pMDI, extrafine particle*, HFA) - Budesonide (DPI) - Budesonide (nebules) - Ciclesonide (pMDI, extrafine particle*, HFA) - Fluticasone furoate (DPI) - Fluticasone propionate (DPI) - Fluticasone propionate (pMDI, standard particle, HFA) - Mometasone furoate (pMDI, standard particle, HFA) | | | | | | | ------------------ | ------------------------- | ---- | ------ | ------ | | **Inhaled Corticosteroid** | **Low** | **Medium** | **High** | | | Beclometasone dipropionate (pMDI, standard particle, HFA) | 100-200 | >200-400 | >400 | | | Beclometasone dipropionate (pMDI, extrafine particle*, HFA) | 50-100 | >100-200 | >200 | | | Budesonide (DPI) | 100-200 | >200-400 | >400 | | | Budesonide (nebules) | 250-500 | >500-1000 | >1000 | | | Ciclesonide (pMDI, extrafine particle*, HFA) | 80 | >80-160 | >160 | | | Fluticasone furoate (DPI) | 50 | - | n.a | | | Fluticasone propionate (DPI) | 50-100 | >100-200 | >200 | | | Fluticasone propionate (pMDI, standard particle, HFA) | 50-100 | >100-200 | >200 | | | Mometasone furoate (pMDI, standard particle, HFA) | 100 | - | 200 | | ## Asma en niños - Diagnóstico diferencial - Age: 6-11 years - Sneezing, itching, blocked nose, throat-clearing - Sudden onset of symptoms, unilateral wheeze - Recurrent infections, productive cough - Recurrent infections, productive cough, sinusitis - Cardiac murmurs - Pre-term delivery, symptoms since birth - Excessive cough and mucus production, gastrointestinal symptoms | | | | ------------------- | ------------------------------------------------------------------------------------------------------ | | 6-11 years | Chronic upper airway cough syndrome, Inhaled foreign body, Bronchiectasis, Primary ciliary dyskinesia, Congenital heart disease, Bronchopulmonary dysplasia, Cystic fibrosis | ## Evaluación del control - Prueba control de asma en niños ## Asma en niños (menores 5 años) - Características clínicas | | | | ------ | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Cough | Recurrent or persistent non-productive cough that may be worse at night or accompanied by wheezing and breathing difficulties. Cough occurring with exercise, laughing, crying or exposure to tobacco smoke, particularly in the absence of an apparent respiratory infection | | Wheezing | Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air pollution. Occurring with exercise, laughing, or crying | | | Not running, playing or laughing at the same intensity as other children; tires earlier during walks (wants to be carried) | | | Other allergic disease (atopic dermatitis or allergic rhinitis, food allergy). Asthma in first-degree relative(s) | | | Clinical improvement during 2-3 months of controller treatment and worsening when treatment is stopped | ## Diagnóstico - Índice predictivo de asma -> EXAMEN | | | | ------------------------------------------------ | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | **A CLINICAL INDEX TO DEFINE ASTHMA RISK** | **Major Criteria** | | | **Minor Criteria** | | | *1. Parental MD asthmat* *2. MD eczemat* | | | *1. MD allergic rhinitis* *2. Wheezing apart from colds* *3. Eosinophilia (≥ 4%)* | | | *Loose index for the prediction of asthma: Early weezer plus at least one of two major criteria or two of three minor criteria. Stringent index for the predication of asthma: Early frequent wheezer plus at least one of two major criteria or two of three minor criteria.* | - *History of a physician diagnosis of asthma.* - *Physician diagnosis of atopic dermatitis as reported in questionnaires at ages 2 or 3.* - *Physician diagnosis of allergic rhinitis as reported in questionnaires at ages 2 or 3.* ## Tratamiento - Children 5 years and younger - Personalized asthma management: Assess, Adjust, Review response - Asthma medication options: Adjust treatment up and down for individual child's needs - PREFERRED CONTROLLER CHOICE - Other controller options - RELIEVER - CONSIDER THIS STEP FOR CHILDREN WITH: - Infrequent viral wheezing and no or few interval symptoms - Symptom pattern not consistent with asthma but wheezing episodes requiring SABA occur frequently. e.g, 23 per year. Give diagnostic trial for 3 months. Consider specialist referral. - Symptom pattern consistent with asthma, and asthma symptoms not well-controlled or ≥3 exacerbations per year.. - STEP 1 - Daily low dose inhaled corticosteroid (ICS) - See table of ICS dose ranges for pre-school children - STEP 2 - Daily leukotriene receptor antagonist (LTRA), or intermittent short courses of ICS at onset of respiratory illness - STEP 3 - Double low dose ICS - STEP 4 - Low dose ICS + LTRA - Consider specialist referral - Add LTRA, or increase ICS frequency, or add intermittent ICS - STEP 5 - Continue controller & refer for specialist assessment - As-needed short-acting B₂-agonist - Asthma diagnosis, and asthma not well-controlled on low dose ICS - Asthma not well-controlled on double ICS - Before stepping up, check for alternative diagnosis. Check inhaler skills, review adherence and exposures - Exclude alternative diagnoses - Symptom control & modifiable risk factors - Comorbidities - Inhaler technique & adherence - Parent preferences and goals - Treat modifiable risk factors and comorbidities - Non-pharmacological strategies - Asthma medications - Education & skills training ## Tratamiento - Aerocnamber de dosis medida es mejor ## Asma en embarazo - Generalidades - “Regla” del 1/3 → 1/3 empeoran, 1/3 mejoran, 1/3 se quedan igual - Exacerbaciones en 2do trimestre - Descontrol - Mayor flujo normonal y mayor volumen intraabdominal - Más complicaciones del embarazo - Embarazo pretermino - Placenta envejece antes por falta de aire - Bajo peso al nacimiento - Alta preocupación por efectos adversos de los medicamentos ## Tratamiento - Asma en el embarazo - Mismo que en no embarazadas - CEI, beta2 agonistas, montelukast y teofilina no asociado a anormalidad fetales - Budesonida mejor perfil de seguridad ## Asma ocupacional - Definición ->