Case Study

Case Study
Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases, Assiut university

Patient Details
 A 20 years old male.
 Smoking Status: Ex-smoker
 His weight is 100 Kg.
 Occupation: Student
 His grandfather died with asthma 4 years ago.

Past respiratory history
 Age at onset of symptoms – Childhood
 Hospitalizations – He was admitted on three occasions.
 Life threatening attacks/ICU admissions/ventilated: 1 ICU
intervention
4

Patient Details (cont.’):
 Cannot socialize with friends.
 Patient’s lifestyle was restricted.
 Unable to participate in any sport
 Gained weight due to lack of physical activity.
 He misses up to 50% of college lectures due to asthma
 Shortness of breath prevented him from using public
transport
 The patient is very depressed as a consequence of his
asthma.

 He has daytime symptoms as breathlessness and
coughing 2 to 3 times per week.
 He uses his rescue treatment around 5 to 6 times per
week.
 He wakes up on the early morning 3 to 4 times per week
due to coughing and chest tightness.

 He is poorly controlled on maximum doses of inhaled
medications
 Despite of taking his medications regularly, He is still
uncontrolled with poor quality of life.

Clinical Findings:
Clinical findings:
Reversibility test ＞ 12% FEV1 improvement.
FEV1= 52% predicted.
Serum Eosinophil count 630 /mm3 .

Allergic status
 Positive skin prick test to grass, cat, dog.
 Total serum IgE 175 IU/ml.
9

Respiratory Medications
(include unsuccessful trials):
 Maximum dose ICS/LABA fixed combination twice daily.
 Tried Leukotriene modifiers and discontinued
 Theophylline.
 Salbutamol when needed.

Medications’ effects
 Mood swings
 Tachycardia
 Nausea
11

Questions
 Guided by the clinical presentation of this patient, what is
your provisional diagnosis for this case? Why?

Severe Asthma Definitions (cont.’):
 Continuing signs of inadequate control in the presence
of nearly continuous use of oral steroids or of maximal
doses of inhaled corticosteroids. (SARP)1.
 One or more acute exacerbations within the past year
despite treatment with at least maximum recommended
doses of inhaled corticosteroids. (ENFUSOMA)2.
Postgrad Med J. 2008 Mar;84(989):115-20
SARP: The Severe Asthma Research Program
ENFUSOMA: European Network for Understanding Mechanismsof Severe Asthma

Definition of The American Thoracic
Society (ATS) for severe asthma:
 Definition requires that at least one major criterion and
two minor criteria are met in the same patient.
Major characteristics:
 Treatment with continuous or near continuous (≥50% of
year) oral corticosteroids.
 Need for treatment with high-dose inhaled
corticosteroids.
Lancet. 2006 Aug 26;368(9537):780-93

Definition of The American Thoracic
Society for severe asthma (cont.’):
Minor Characteristics:
 Need for additional daily treatment with a controller medication (e.g.
Long-acting β agonist, theophylline, or leukotriene antagonist)
 Asthma symptoms needing short-acting β agonist use on a daily or
near-daily basis
 One or more urgent care visits for asthma per year
 Three or more oral steroid bursts per year
 Near-fatal asthma event in the past
Lancet. 2006 Aug 26;368(9537):780-93

International ERS/ATS Guidelines on Definition,
Evaluation and Treatment of Severe Asthma
December 2013

 When a diagnosis of asthma is confirmed and comorbidities
have been addressed, severe asthma is defined as “asthma
which requires treatment with high dose inhaled
corticosteroids (ICS) plus a second controller (and/or
systemic CS) to prevent it from becoming “uncontrolled” or
which remains “uncontrolled“ despite this therapy.”
Definition of Severe Asthma

Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb
Inhalation Suspension
250-500 >500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation

Smooth Muscle
Dysfunction
Airway
Inflammation
• Inflammatory Cell
Infiltration/Activation
• Mucosal Edema
• Cellular Proliferation
• Epithelial Damage
• Basement Membrane
Thickening
• Bronchoconstriction
• Bronchial Hyperreactivity
• Hypertrophy/Hyperplasia
• Inflammatory Mediator
Release
Symptoms/Exacerbations
Asthma Pathobiology

Questions
 What are the risk factors that associated with this case?

Risk factors associated with this case
 Medical History
 Family history

Risk Factors &
Associated Characteristics of
Severe Asthma

Risk Factors:
 In most cases, multiple factors are responsible for
difficult-to-treat asthma.
 Many of the risk factors that contribute to disease
chronicity are also triggers of worsening asthma and
exacerbations, indicating complex interactions with the
environment.
Lancet. 2006 Aug 26;368(9537):780-93

Risk Factors (cont.’):
 ENFUMOSA is among several studies that have found
higher concentrations of neutrophils in induced sputum
or bronchoscopic biopsy specimens from patients with
severe asthma than in samples from patients with mild-
to-moderate asthma.
 This neutrophil predominant inflammation is significant
because corticosteroids may protect these cells from
undergoing apoptosis.
1-Neutrophils

 The genetics of asthma is a growing focus of interest,
with a number of mutations having been associated
with increased asthma risk.
 Several of these mutations, are associated with an
increased likelihood that asthma will be severe.
 One such example is a mutation in the promoter region of
transforming growth factor b1 (TGF-b1)
 TGF-b1 is a pro-fibrotic cytokine that induces secretion of
extracellular matrix proteins and thus could contribute to
airway remodelling.
2-Genetics

 The frequency of this mutation in patients with severe
asthma was twice as great as in those with mild asthma
and more than five times as great as in control subjects
2-Genetics

 Severe asthma is two to three times more common in
women than in men,
 At its inception in childhood, asthma is more common in
boys, but during the early teenage years severe asthma
becomes more common in girls than in boys and this
pattern persists into adulthood.
 The higher prevalence of adult-onset asthma and severe
asthma in women than in men is probably the result of
endocrine factors
Lancet. 2006 Aug 26;368(9537):780-93
3-Endocrine Factors:

 Strong associations have been reported with the
menstrual cycle, whereas in pregnancy asthma
commonly improves, especially in the mid and late
trimesters.
 Thyrotoxicosis is a recognized endocrine factor leading
to loss of asthma control.
 Obesity is a newly recognized risk factor for both asthma
and its severity, especially in women, with weight loss
being accompanied by improved asthma control.
Lancet. 2006 Aug 26;368(9537):780-93
3-Endocrine Factors:

Risk Factors (cont):
 The co-existence of chronic rhinitis, nasal polyposis,
and sinusitis contribute to asthma severity.
 Gastro-esophageal reflux is also commonly associated
with chronic asthma both in adults and children, possibly
related to the proximity of the organs and neural
connections.
Lancet. 2006 Aug 26;368(9537):780-93
4-Comorbid Diseases:

 Severe asthma has long been associated with
psychological and psychiatric disorders, which are
particularly strong risk factors for frequent emergency
room visits and asthma mortality with depression,
anxiety, panic or fear, and behavioral problems that
adversely affect disease control.
Lancet. 2006 Aug 26;368(9537):780-93
5-Psychopathological Factors:

 β blockers can lead to severe asthma that is refractory
to β2-adrenoceptor agonists. Asthma is, therefore, a
contraindication for this drug class.
 Inhibitors of angiotensin converting enzyme and
adenosine for cardiovascular diseases are also
associated with deterioration of asthma.
 However, aspirin and non-steroidal anti-inflammatory
drugs (NSAIDs) present the most common and difficult
problems.
 Aspirin intolerance has emerged as a prominent risk
factor of severe asthma.
Lancet. 2006 Aug 26;368(9537):780-93
6-Adverse Drug Effects:

Do oral Beta Blockers Really
Exacerbate Asthma?
Recent investigations suggest BB therapy may
actually improve asthma. A 2002 meta-
analysis found no significant adverse effects of
beta-blocker therapy in people with mild-to-
moderate asthma, and in fact, bronchodilator
response increased with chronic beta-blocker
treatment.
Thorax 2011;66:502-507.

 Asthma is a complex disease or a syndrome that includes
several disease variants.
 The term asthma, like „arthritis‟, equates to a definition of
grouped clinical and physiological characteristics. These
characteristics could identify syndromes, phenotypes or even
multiple diseases rather than a single disease.

 For revealing the complexity and the heterogeneity of this
disease, asthma patients were grouped into subtypes called
phenotypes.
 Term „phenotype‟ describes subtypes of asthma focused on
„clinically observable characteristics‟of a disease.

 Therefore, there are many „definitions‟for asthma phenotypes, many of
which are related to differences in symptoms and severity rather than to
differences in underlying mechanisms. but this kind of subtyping does
little to help understand prognosis and target therapy.
 When a link can be made between clinical characteristics and molecular
pathways, the term endotype can be introduced to describe distinct
subtypes with a defining etiology and consistent pathobiologic
mechanisms.

 The definition of a true phenotype (or endotype) requires an
underlying pathobiology with identifiable biomarkers and
genetics .
 Gene-expression profiling allows definition of expression
signatures to characterize patient subgroups, predict response
to treatment, and offer novel therapies.

 By The study of wenzel ,et al 2013 Combining clinical, statistical
and molecular approaches two broad emerging “endotypes” have
been defined.
 Traditionally asthma has been thought to be a Th2-associated
disease. There is strong evidence supporting a TH2-high phenotype
in up to 50% of people with asthma of any severity, yet 50% show
no evidence for this immune process.

These patients are characterized by atopy, eosinophilic
inflammation and favorable response to corticosteroids.
 Early-onset allergic asthma
 Late-onset persistent eosinophilic asthma
 Exercise induced asthma

Clinical characteristics:
 This group of asthmatic patients developed their disease in
childhood, and maintained their symptoms into adulthood. .
The majority of early-onset allergic asthma is mild but that an
increasing complexity of immune processes leads to greater
severity.
 Most people with asthma are likely to have this phenotype.
 Positive skin prick tests, specific IgE antibodies in serum,
eosinophilia in the peripheral blood .

Genetics:
Early-onset allergic patients commonly have a family history of
asthma, suggesting a genetic component.
 Several Th2 cytokine SNPs
 higher numbers of mutations in TH2-related genes (IL4, IL13,
IL4Rα ) associated with greater severity of disease.

Biomarkers:
 Positive SPT, elevated IgE/elevated FeNO
 Th2 cytokines IL-4 ,IL-5 , IL-9, IL-13, and periostin measured in
sputum, BAL, serum and bronchial biopsies.
Treatment responses:
Corticosteroid-responsive.
Th2 Targeted therapy:
 Anti IgE (omalizumab)in Severe allergic asthma.
 Anti–IL-13( lebrikizumab) in Allergic asthma with dominant IL-13
activation Surrogate marker predicting better response is high
circulating levels of periostin. .

 Inhaled IL-4Rα antagonist . Surrogate marker predicting
better response is IL-4 receptor a polymorphism.

The majority of this group develops disease in adult life,
often in the late 20s to 40s.
 Severe from onset, Severe exacerbations with persistent
sputum eosinophilia (>2%), despite corticosteroid
therapy.
 less clinical allergic responses( non atopic) than early-
onset asthma.
 It is often associated with sinus disease.

Genetics:
 Few patients in this group have a family history of asthma.
 little is known regarding the genetics of adult onset persistent
asthma.

Biomarkers:
 Lung eosinophilia. Persistent sputum eosinophilia (≥2%)
 The lack of clinical allergy in this phenotype suggests that the TH2
process differs from and is probably more complex than the one
associated with the early-onset allergic phenotype but the presence
of IL-13 and IL-5 in the lower airways confirm Th2 pathway.
 Some individuals show sputum neutrophilia intermixed with their
eosinophilic process. This mixed inflammatory process implies that
there are interactions of additional immune pathways with TH2
immunity, including activation of pathways related to IL-33 and IL-
17 .
 Elevations in FeNO

 persistent eosinophilia in late-onset disease inspite of ICS implies that the
TH2 process in this type of asthma is refractory to corticosteroids but high
systemic doses of corticosteroids are generally able to overcome this
refractoriness in late-onset asthma.
 IL-5 targeted therapy may show much better efficacy in this endotype,
compared in early-onset allergic asthma patients, as IL-5 dependent
eosinophilia may be more important in this potential endotype.
(decreasing exacerbations and systemic corticosteroid requirements)
 L-4 and IL-13 targeted therapy pathway.

AERD is probably a subendotype or a similar endotype. It is an
acquired condition on top of an intrinsic or less frequently
allergic asthma and thus, despite its peculiar sensitivity to
NSAIDs, still has major overlap with these conditions.
Clinical characteristics :
 AERD is frequently progressive severe asthma starts late in
life and is associated with eosinophilia and sinus disease
Polyposis.
 Response to aspirin challenge

Genetics :
 LT-related gene polymorphisms.
 Gene-expression study identified upregulation of periostin a
potent regulator of fibrosis and collagen deposition has also
been identified in polyps of and in airway epithelial cells of
patients with AIA.
Overexpression of periostin has been associated with
accelerated cell growth and angiogenesis(subtype).
Biomarkers:
high cysteinyl leukotriene level.

Treatment responses :
 Many patients require systemic corticosteroids to control their
sinusitis and asthma.
 Leukotriene modifiers especially 5-LO inhibitors can have a
robust impact on the AERD subset.
 Downregulation of periostin after treatment of asthmatic
patients with corticosteroids suggests that normalization of
periostin expression is a part of the therapeutic effects of
corticosteroids. This opens a possibility of specifically
targeting periostin in future therapies for nasal polyps and
asthma

 Exercise induced asthma refers to asthma whose symptoms are
experienced primarily after exercise. EIA is a milder form of
TH2 asthma.
 Consistent with a relationship to TH2 processes, EIA common
in atopic athletes and high percentages of eosinophils and
mast cells and their mediators .

Biomarkers:
 Th2 cytokines and cysteinyl leukotriene
Genetics:
 No distinct genetic factors .
 Leukotriene modifiers high LTE4/FENO ratio is Surrogate
marker predicting better response.
 IL-9 targeted therapy has been shown effective on patients of
this group, which implies that Th2 immunity is involved in the
pathophysiology of EIA.

The lack of efficacy of Th2 targeted therapy suggests that a
subgroup of asthma develops in the absence of Th2 immunity .
Little is understood about the non Th2 asthma and its related
molecular elements.
 Obesity-related asthma
 Neutrophilic asthma
 Smoking asthma

Whether obesity is a driving component in asthma development
or a mere confounder or comorbidity of its presence remains
controversial.
It is likely that obesity differentially impacts asthma that
develops early in life, as compared to later in life, being a more
prominent independent contributor in later onset disease.
So a distinct obesity-related asthma phenotype seems to occur
only in non-TH2 asthma.
 ,
 ..

Clinical characteristics :
Patients in this group are commonly women, obese, late onset
(mid-40s), less allergic (obesity is neither a risk factor for atopy
nor a risk factor for allergic asthma).with a high burden of
symptoms.

Biomarkers:
 High expression of non Th2 mediators such as tumor
necrosis factor (TNF)-a, IL-6 .
 Hormones of obesity, such as adiponectin, leptin, and resistin
either alone or in association with increased oxidative stress.
 Elevations in an endogenous inhibitor of iNOS, asymmetric
dimethyl arginine (ADMA).
 lower amounts of FeNO, fewer eosinophils.

 Patients of this subgroup usually respond poorly to corticosteroids.
 Bariatric surgery induced weight loss was associated with profound
improvements in lung function and symptoms in obese asthma.
 However, the effect of weight loss on bronchial hyper responsiveness
was only shown in late-onset, nonallergic (non-Th2) asthma patient,
consistent with late onset obese asthma being a separate endotype. This
is further supported by the increase in ADMA in association with
worsening severity and control in late onset obese asthma only.

Clinical characteristics and biomarkers:
 It remains controversial whether neutrophilia is an independent driving
component, a synergistic factor with eosinophilia or just a consequence of
corticosteroid therapy.
 Still unclear whether this represents a unique form of asthma or just a
different stage of severity or persistent bacterial colonization or infection of
the airways on the background of a previously eosinophilic asthma.
 Airway pathophysiology in neutrophilic asthma is characterized by (fixed)
airflow limitation more trapping of air, thicker airway walls (as
measured by CT) .

 Novel mechanisms implicated in the pathogenesis of
noneosinophilic asthma involve the activation of innate immune
responses with a possible role of bacteria, viruses.
 Neutrophilia can also co-exist with eosinophilia, and this identifies
the people with the most severe asthma and emphasizes the
complexity of the immunobiology of severe asthma in which
multiple different innate and adaptive immune pathways and cells
may have roles.
 Impaired nuclear recruitment of histone deacetylase (HDAC).
 The role of TH17 immunity

Biomarkers:
 IL-8, IL-17A, LTB4, and possibly IL-32.
 IL-1 and TNF-α pathways are upregulated and associated with
neutrophilic inflammation in a sputum gene-expression study.
 low levels of FeNO.

 Corticosteroids are less effective in patients of this subgroup.
 Macrolide antibiotics may have some efficacy on neutrophilic
asthma, By modulating the innate immune response in the
lung, by reducing the expression of neutrophilic markers .
 Restoration of HDAC 2 nuclear recruitment with theophylline.
 Anti-TNF-α responsive( infliximab )
 The efficacy of IL-17 targeted therapy in this subtype of
asthma awaits evidence from ongoing clinical trials.

 Smoking has a complex relationship with asthma. It is
associated with deteriorating lung function and resistance to
corticosteroids.
 Smoking asthma has been associated with neutrophilia in lung
tissue.
 It is unknown if smoking asthma is a subtype of neutrophilic
asthma or an independent endotype . Since not all smoking
asthma is accompanied by neutrophilia, it is more likely that
there is only a partial overlap between neutrophilic asthma and
smoking asthma.

 Some reports have suggested that smoking is associated with
elevated total IgE and that active smoking may increase the risk of
sensitization to workplace allergens.
 However, little is understood regarding the role of genetics,
biomarkers or pathobiology.
 FeNO levels are decreased by smoking and could help to
differentiate asthmatic subjects from non-asthmatic subjects.
Treatment responses
 Quitting smoking
 Restoration of HDAC 2 nuclear recruitment with theophylline.

The intensity of the colors represents the range of severity; the relative sizes
of the subcircles suggest relative proportions of affected individuals

Lötvall et al.2011 proposed endotyping asthma into six classes
depending on several parameters used to define an endotype.
 Aspirin sensitive asthma
 Allergic asthma (adults)
 Severe late-onset hypereosinophilic
 ABPM
 API-positive preschool wheezer
 Asthma in cross country skiers

The Asthma–Chronic Obstructive
Pulmonary Disease Overlap
Syndrome (ACOS)

The Spanish COPD guidelines propose
four COPD phenotypes that determine
differential treatment: nonexacerbator
with emphysema or chronic bronchitis,
mixed COPD–asthma, exacerbator with
emphysema and exacerbator with
chronic bronchitis
ACOS

ACOS
The mixed COPD–asthma phenotype was
defined as an airflow obstruction that is not
completely reversible accompanied by
symptoms or signs of an increased
reversibility of the obstruction.[7] In other
guidelines, these patients are described as
'patients with COPD and prominent asthmatic
component' or as asthma that complicates
COPD.

ACOS
The following major criteria for ACOS:
a physician diagnosis of asthma and COPD in the
same patient, history or evidence of atopy, for
example, hay fever, elevated total IgE, age 40 years
or more, smoking >10 pack-years,
postbronchodilator FEV1 <80% predicted and
FEV1/FVC <70%.
Minor criteria:
A ≥15% increase in FEV1 or ≥12% and ≥200 ml
increase in FEV1 postbronchodilator treatment with
albuterol .

78
Lessons learnt from
studies of asthma deaths
Management of acute asthma. Thorax 2012
B
Health care professionals must be aware that patients with severe
asthma and one or more adverse psychosocial factors are at risk of
death

Keep patients who have had near fatal asthma or brittle asthma
under specialist supervision indefinitely

Respiratory specialist should follow up patients admitted with
severe asthma for at least a year after admission
Many deaths from asthma are preventable – 88-92% of attacks requiring
hospitalisation develop over 6 hours
Factors include:
• inadequate objective monitoring
• failure to refer earlier for specialist advice
• inadequate treatment with steroids

79
Levels of severity of
acute asthma exacerbations
Near fatal asthma Raised PaCO2 and/or requiring mechanical ventilation with raised
inflation pressures

80
Near fatal asthma Raised PaCO2 and/or requiring mechanical ventilation with
raised inflation pressures
Life threatening
asthma
Any one of the following in a patient with severe asthma:
• Altered conscious level
• Exhaustion
• Arrythmias
• Hypotension
• Cyanosis
• Silent chest
• Poor respiratory effort
• PEF <33% best or
predicted
• SpO2 <92%
• PaO2 <8 kPa
• “normal” PaCO2
(4.6–6.0 kPa)

81
inflation pressures
Life threatening
asthma
•PEF <33% best or
predicted
•SpO2 <92%
•PaO2 <8 kPa
•normal PaCO2 (4.6-6.0 kPa)
•silent chest
•cyanosis
•feeble respiratory
effort
•bradycardia
•dysrhythmia
•hypotension
•exhaustion
•confusion
•coma
Acute severe
asthma
Any one of:
• PEF 33-50% best or predicted
• respiratory rate 25/min
• heart rate 110/min
• inability to complete sentences
in one breath

82
inflation pressures
Life threatening
asthma
•PEF <33% best or
predicted
•SpO2 <92%
•PaO2 <8 kPa
•normal PaCO2 (4.6-60 kPa)
•silent chest
•cyanosis
effort
•bradycardia
•dysrhythmia
•hypotension
•exhaustion
•confusion
•coma
Acute severe
asthma
Any one of:
•PEF 33-50% best or predicted
•respiratory rate 25/min
•heart rate 110/min
•inability to complete sentences
in one breath
Moderate asthma
exacerbation
• Increasing symptoms
• PEF >50-75% best or predicted
• No features of acute severe
asthma

83
inflation pressures
Life threatening
asthma
•PEF <33% best or
predicted
•SpO2 <92%
•PaO2 <8 kPa
•normal PaCO2 (4.6-6.0 kPa)
•silent chest
•cyanosis
effort
•bradycardia
•dysrhythmia
•hypotension
•exhaustion
•confusion
•coma
Acute severe
asthma
Any one of:
•PEF 33-50% best or predicted
•respiratory rate 25/min
•heart rate 110/min
•inability to complete sentences
in one breath
Moderate asthma
exacerbation
•Increasing symptoms
•PEF >50-75% best or predicted
•No features of acute severe
asthma
Brittle asthma • Type 1: wide PEF variability (>40% diurnal variation for >50% of
the time over a period >150 days) despite intense therapy
• Type 2: sudden severe attacks on a background of apparently
well-controlled asthma

84
Initial assessment – the role of
symptoms, signs and measurements
Clinical features Clinical features can identify some patients with severe asthma,
eg severe breathlessness (including too breathless to complete
sentences in one breath), tachypnea, tachycardia, silent chest,
cyanosis, accessory muscle use, altered consciousness or
collapse.
None of these singly or together is specific. Their absence does not
exclude a severe attack.

85
Clinical features Clinical features, symptoms and respiratory and cardiovascular signs
helpful in recognising severe asthma, but none specific, and their absence
does not exclude a severe attack
PEF or FEV1 Measurements of airway caliber improve recognition of the
degree of severity, the appropriateness or intensity of therapy, and
decisions about management in hospital or at home.
PEF or FEV1 are useful and valid measures of airway caliber. PEF is
more convenient in the acute situation.
PEF expressed as a percentage of the patient‟s previous best value
is most useful clinically. PEF as a percentage of predicted gives
a rough guide in the absence of a known previous best value.
Different peak flow meters give different readings. Where possible
the same or similar type of peak flow meter should be used.

86
PEF or FEV1 Measurements of airway calibre improve recognition of severity and guide
hospital or at home management decisions. PEF is more convenient and
cheaper than FEV1. PEF as % previous best value or % predicted most
useful
Pulse oximetry Measure oxygen saturation (SpO2) with a pulse oximeter to
determine the adequacy of oxygen therapy and the need for arterial
blood gas (ABG) measurement. The aim of oxygen therapy is to
maintain SpO2 94-98%.

87
Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92
useful
Pulse oximetry Necessary to determine adequacy of oxygen therapy and need for arterial
blood gas measurement. Aim of oxygen therapy is to maintain SpO2 92%
Blood gases
(ABG)
Measure oxygen saturation (SpO2) with a pulse oximeter to
determine the adequacy of oxygen therapy and the need for arterial
blood gas (ABG) measurement. The aim of oxygen therapy is to
maintain SpO2 94-98%.

88
Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92
useful
Blood gases
(ABG)
Necessary for patients with SpO2 <92% or other features of life threatening
asthma
Chest X-ray Not routinely recommended in patients in the absence of:
• suspected pneumomediastinum or
pneumothorax
• suspected consolidation
• life threatening asthma
• failure to respond to treatment
satisfactorily
• requirement for ventilation

89
useful
Blood gases
(ABG)
Necessary for patients with SpO2 <92% or other features of life threatening
asthma
Chest X-ray Not routinely recommended in patients in the absence of:
•suspected pneumomediastinum or
pneumothorax
•suspected consolidation
•life threatening asthma
•failure to respond to treatment
satisfactorily
•requirement for ventilation
Systolic paradox Abandoned as an indicator of the severity of an attack

Radiographic Signs of Pneumomediastinum
Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Extrapleural sign
Air in the pulmonary ligament

International ERS/ATS
Guidelines on Definition,
Evaluation and Treatment of
Severe Asthma

 When a diagnosis of asthma is confirmed
and comorbidities have been addressed,
severe asthma is defined as “asthma which
requires treatment with high dose inhaled
corticosteroids (ICS) plus a second controller
(and/or systemic CS) to prevent it from
becoming “uncontrolled” or which remains
“uncontrolled“ despite this therapy.”
Definition of Severe Asthma

Recommendation
 CT chest
 Sputum eosinophil count
 Exhaled NO
 Omalizumab
 Methotrexate
 Macrolide antibiotics
 Antifungal agents
 Bronchial thermoplasty

Questions
 Guided by guidelines, what’s our Goal of managing this
case?

GINA Goals For Asthma Management:
 Achieve and maintain control of symptoms.
 Maintain normal activity levels.
 Prevent asthma mortality.
 Maintain pulmonary function as close to normal.
 Prevent asthma exacerbations.
Adapted from Global strategy for Asthma management and prevention guidelines 2012.

Goals for this case
 Patient Goals
- Reduction in symptoms
- To improve quality of life.
- To complete college
course.
 HCP Goal
• Reduction in healthcare
utilization
• Improvement in patient’s
QoL.
• Reducing exacerbation
frequency.
• Reduce the potential for
repeated admissions

Questions
case?
 What is the classification for this case?

Level of Control:
 Regarding the mentioned case:
 He has daytime symptoms. (He misses college).
 He has limitation of activities (Unable to participate in sports).
 Regarding the nocturnal awakening. (He wakes up at the early
morning) (3 to 4 times/week).
 He uses his rescue treatment more than twice/week (5 to 6
times/week).
 Lung function FEV1＜ 80% (FEV1 = 52%).

Levels of Asthma Control
Characteristics
Controlled
(All of the
following)
Partly controlled
(Any measure
present)
Uncontrolled
Daytime symptoms None (twice or
less/week)
More than
twice/week
Three or more
features of partly
controlled
asthma
Limitation of activities None Any
Nocturnal symptoms/
Awakening
None Any
Need for reliever/rescue
treatment
None (twice or
less/ week)
More than
twice/week
Lung function (PEF or
FEV1)
Normal <80% predicted or
personal best (if
known)
Assessment of current clinical control (preferably over 4 weeks)
Adapted from Global strategy for Asthma management and prevention guidelines 2012

Questions
case?
 What is the classification for this case?
 How can we manage this case?

Treatment Options
Maintain
Treatment
Step 4

Treatment according To guidelines:
Adapted from Global strategy for Asthma management and prevention guidelines 2012.
Treatment Steps
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education
Environmental control
As needed rapid-
acting β2-agonist
As needed rapid-acting β2-agonist
Controller options
Select one Select one
To step 3 treatment,
select one or more
To step 4 treatment,
add either
Low-dose ICS Low-dose ICS plus LABA
Medium- or high-dose
ICS plus LABA
Oral corticosteroid
(lowest dose)
Leukotriene modifier Medium- or high-dose ICS Leukotriene modifier Anti-IgE treatment
Low-dose ICS plus
Leukotriene modifier
Sustained release
Theophylline
Low-dose ICS plus sustained
release Theophylline
Reduce Increase

The Mentioned Case Is Classified As:
•Uncontrolled (According to the GINA classification for the
level of control).
•GINA step 5 (according to the treatment steps).
•Allergic(Atopic) (+ve skin test to 2 allergens).
 Despite of taking his medications even with high doses
regularly he is:

Treatment Options
Maintain
Treatment
Step 4
Oral
Corticosteroids

Side effects of Oral Corticosteroids?!
 OCS are used sparingly due to a broad array of serious
adverse events including:
• Bone fractures
• Osteoporosis
• Susceptibility to infections
• Hyperglycemia
• Obesity
• Psychiatric condition
• Hypertension
• Skin condition
• Adrenal insufficiency
• Ocular condition
• Non-Hodgkin lymphoma
• Deep vein thrombosis
• Cardiac condition
• Weakness
• Abnormal hair growth
• Gastric condition
• Impaired growth
S.C. Manson et al. Respiratory Medicine (2009) 103, 975-994

Not only do the identified adverse events have a strong
negative impact on the health of patients, but they also
have economic and societal consequences as well.

Steroid avoidance became a key focus
 As the multi-faceted negative consequences of OCS
therapy are becoming better understood, the drive to find
OCS substitutes becomes more urgent
 Steroid avoidance has become a key focus in the effective
management of patients treated with OCS

Treatment Options
Maintain
Treatment
Step 4
Oral
Corticosteroids
Anti-
IgE

What Is Anti-IgE (Xolair®) Treatment?

Murine MAb Humanized IgG
Xolair®
Humanizing the anti-IgE monoclonal antibody:
Xolair®
5% murine residues

Allergic
inflammation:
Eosinophils and
lymphocytes
Asthma
exacerbation
Omalizumab Mechanism of Action in IgE
Mediated Asthma
Perennial
aeroallergens
Allergic
mediators
Omalizumab
1-Binds to free
IgE, reducing
cell-bound IgE
2-Reduces
high-affinity
receptors
4-Reduces asthma
exacerbations and
symptoms
B lymphocyte
Release
of IgE
Mast cells
Basophils
Plasma cell
3-Reduces
mediator release

Omalizumab
IgE
Xolair (Omalizumab) binds to the region of IgE
that interact with IgE receptors
C3
region

Xolair interrupts the allergic cascade by inhibiting the
crosslinking of IgE by allergen fragments.

Indication:
Xolair Basic Prescribing Information

Dosage and Administration:
 The appropriate dose and dosing frequency of Xolair® is
determined by baseline immunoglobulin E (IgE) (IU/mL),
measured before the start of treatment, and body weight
(kg).
 Prior to initial dosing, patients should have their IgE level
determined for their dose assignment.
Xolair® Basic Prescribing Information

Dosage and Administration (cont):
 For subcutaneous administration (every 2 or 4 weeks) only
in the deltoid region of the arm.
 Alternatively, the injections can be administered in the thigh
if there is any reason precluding administration in the deltoid
region of the arm.

Dosage and Administration (cont):
 Do not administer by the intravenous or intramuscular
route.
 There is limited experience in the self administration of
Xolair®.
 Therefore, treatment is intended to be administered by a
healthcare professional.

Dosing:

Treatment duration, monitoring and
dose adjustments
 In clinical trials there were reductions in asthma
exacerbation events and rescue medication use with
improvements in symptom scores during the first 16
weeks of treatment.
 At 16 week after commencing Xolair® therapy patients
should be assessed by their physicians for treatment
effectiveness before further injections are administered.

Treatment duration, monitoring and
dose adjustments
 Discontinuation of treatment generally results in a return
to elevated free IgE levels and associated symptoms.

 Total IgE levels are elevated during treatment and remain
elevated for up to one year after the discontinuation of
treatment.
 Therefore, re-testing of IgE levels during Xolair® treatment
cannot be used as a guide for dose determination.
Treatment duration, monitoring and dose
adjustments

 Dose determination after treatment interruptions lasting
less than one year should be based on serum IgE levels
obtained at the initial dose determination.
 Total serum IgE levels may be re-tested for dose
determination if treatment with Xolair® has been
interrupted for one year or more.
 Doses should be adjusted for significant body weight
Changes.
Treatment duration, monitoring and dose
adjustments

INNOVATE
INvestigatioN of Omalizumab in seVere Asthma
TrEatment
Humbert M, et al. Allergy 2005 (60): 309-316

The INNOVATE Study
• The primary objective of the
INNOVATE study was to evaluate the
effect of add-on omalizumab on
asthma exacerbations in patients with
severe persistent asthma who were
inadequately controlled despite GINA
step 4 therapy, which comprises high-
dose ICS plus LABA and additional
controller medication if required
Objective

Study design
Screening
tests
(7 days)
28 weeks
Omalizumab (n=209) or placebo
(n=210) as
add-on to GINA step 4 therapy
Off
study
drug
Randomization
Run-in phase
(8 weeks)
Follow-up
(16 weeks)
A 28-week randomized double-blind, placebo-controlled study

Omalizumab
(n=209)
Placebo
(n=210)
1.2
1.0
0.8
0.6
0.4
0.2
0
Clinicallysignificant
asthmaexacerbationrate
Omalizumab significantly reduces
clinically significant exacerbations
 26%
p=0.042
0.68
0.91

Xolair® Significantly Reduces Severe
Exacerbation Rate

Xolair® Significantly Reduces Emergency
Visits Due to Asthma Worsening

Xolair® Significantly Improved Overall QoL
& Across All Domains
49% improvement in Overall QoL with Omalizumab
49% 40% 55% 51% 49%

Omalizumab was well tolerated
 The percentage of patients who experienced adverse
events (AEs) was similar in both treatment groups.
- Omalizumab, 72.2%; placebo, 75.5%
 Fewer serious AEs in the Omalizumab group.
- Omalizumab, 11.8%; placebo, 15.6%
 AEs were generally mild or moderate in nature and of
short duration.

Italian Real Life Experience
M. Cazzola et al, Respiratory Medicine (2010) 104, 1410-1416

Study Design
 A 12-month, prospective observational trial conducted
in a real-life setting evaluating the efficacy of
omalizumab as an add-on treatment in 142 patients
with uncontrolled severe persistent allergic asthma.
 Data was collected at baseline, month 4, 8 and 12.
 The evaluation performed at the end of the study
(month 12). Patients treated with omalizumab for at
least 4 months (n =130).

With Xolair®: Effective reduction of emergency
visits and hospitalizations
p < 0.001

 Pooled analysis of seven trials (24-52 weeks long) were
included on common study efficacy variables.
 With objective of testing the association between the effect
of OMA on need for rescue bursts of systemic steroids
(SB).
 4308 patients were in the pooled analysis (2511 OMA,
1797 control)
145
Maykut R, et al. J Allergy Clin Immunol 2006;117(2):S10,39 (abstract).

Xolair® significantly reduces the need for
systemic corticosteroid bursts: Pooled Analysis.
0.4
0.6
Steroidbursts(mean)
Omalizumab
(n=2,511)
Control
(n=1,797)
0.8
0.6
0.4
0.2
0
p<0.001
Maykut R, et al. J Allergy Clin Immunol 2006;117(2):S10,39 (abstract).
Relative risk: –43.0%

Conclusion
 Xolair® is indicated for adults and children (6 years and
above) with moderate to severe persistent allergic asthma
whose symptoms are inadequately controlled with ICS.1
 Omalizumab significantly reduces clinically significant
exacerbations.2
 Xolair® Significantly Reduces Severe Exacerbation Rate.2
Allergy 2005;60:309–16

Conclusion
 Xolair® Significantly Reduces Emergency Visits Due to
Asthma Worsening.2
 Xolair® Significantly Improved Overall QoL & Across All
Domains.2
 Xolair® Effectively reduced emergency visits and
hospitalizations.
 Xolair® significantly reduced the need for systemic
corticosteroid bursts
1-Allergy 2005;60:309–16
2- M. Cazzola et al, Respiratory Medicine (2010) 104, 1410-1416
3- Maykut R, et al. J Allergy Clin Immunol 2006;117(2):S10,39 (abstract).

Case Study

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (20)

Ähnlich wie Case Study

Ähnlich wie Case Study (20)

Mehr von Gamal Agmy

Mehr von Gamal Agmy (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Case Study