here management of asthma describes in details with particular emphasis on newer advances based on recent gina guidelines.

1. ADVANCES IN ASTHMA MANAGEMENT
SPEAKER: PRAGATI DATTTA
CHAIRPERSON : DEBALINA SARKAR

2. ASTHMA :
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Heterogenous
airway inflammation – eosinophilic , neutrophilic
Hyperresponsiveness of the airway
Reversible bronchoconstriction , mucus hypersecretion
Variable expiratory airflow limitation
Importance of recognizing asthma phenotypes

3. Classification of asthma phenotypes in children
Sympto
m based
Trigger
based
Response to
treatment
Inflammatory
changes
Non-invasive
Markers
Pulmonary
function tests

4. New in the diagnosis of asthma
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Fractional exhaled nitric oxide testing-
FeNO is a noninvasive marker of airway inflammation
the 2011 American Thoracic Society guidelines recommended <20 ppb
for low and >35 ppb for high FeNO cut-offs in children to determine
eosinophilic inflammation and response to steroid
a recent study concluded that FeNO concentration has moderate
accuracy to diagnose asthma above 5 years *
* Wang Z,Pianosi PT,Keogh KA,et al. The diagnostic accuracy of fractional exhaled nitric oxide testing in
asthma: a systemic review and meta analyses. Mayo Clin Proc.2018;93:191-8

5. Identification and treatment of co-morbities of
asthma
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Rhinitis
Rhinosinusitis
Nasal polyposis
Obesity
GERD
Stress , anxiety symptoms
Dysfunctional breathing – exercise induced laryngeal obstruction

6. New in the management of acute asthma
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Inhalational or intravenous magnesium sulfate
Dexamethasone or prednisolone ?*
High flow nasal cannula oxygen or face mask oxygen
* Abaya R,Jones L, Zorc JJ. Dexamethasone compared to prednisolone for the treatment of children with
acute asthma exacerbations. Pediatr Emerg Care. 2018;34:53-8

7. New in the long term management of asthma
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GOALS –
Minimize short term effects – day to day symptoms, disturbed sleep,
activity limitation
Minimize adverse asthma outcomes – attacks , persistent airflow
limitation , medication side- effects

8. Pharmacological treatment
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Inhaled corticosteroids along with short acting beta-2 agonists in
initial treatment of asthma
Restriction of use of regular short acting beta-2 agonists
Long acting muscarinic antagonist – tiotropium
tiotropium delivered via Respimat SoftMist inhaler approved for
asthma in children over 6 yrs in USA *
GINA guidelines recommend tiotropium as add-on therapy option at
steps 4 and 5 in patients aged 12 years and above
*Hamelmann E, Szefler SJ. Efficacy and safety of tiotropium in school age children with moderate to severe
symptomatic asthma: a systematic review.Pediatr Allergy Immunol. 2017;28:573-8

9. Respimat soft mist
Inhaler

10. Biological monoclonal antibody treatment
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Omalizumab – anti-IgE …now licensed for moderate to severe allergic
asthma in children aged at least 6 years…given every 2-4 week
subcutaneously…reduces exacerbation…anaphylaxis being an important
side effect
Mepolizumab – targets IL-5…recently approved for severe eosinophilic
asthma in adults but not for children less than 12years…improve
asthma control, reduce prednisolone dose
Dupilumab – anti IL-4 receptor antibody…shows promising results in
adult studies.

11. Allergen specific immunotherapy
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Subcutaneous immunotherapy requiring repeated injections with an
allergen extract like grass, tree pollen, house dust mite
Important benefit is steroid sparing effect in patients requiring high
dose of steroids
Because of limited benefits not recommended in children

12. Vitamin D for the management of asthma
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Vitamin D has antimicrobial, antiviral and anti-inflammatory actions
Evidence shows inadequate vitamin D status in children with asthma
Recent meta-analysis suggests vitamin D likely to reduce severe
asthma exacerbations in mild to moderate asthma
Macrolide Antibiotics
study on adults with moderate to severe asthma showed decreased
exacerbations with oral azithromycin….but the role is uncertain in
children and long term macrolides not recommended at present

13. Temperature- controlled Laminar Airflow
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Reduction in allergen/particulate exposure
Works by controlling nocturnal exposure to particulate exposure by
delivering cooled and filtered air overhead
Showed significant improvement in asthma specific quality of life and
significantly decreased FeNO

15. Electronic monitoring and Adherence Devices
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Adherence in asthma treatment remains a major barrier to effective
control
Electronic device that can be attached to MDI…can record an
actuation…audio reminder for the child and parent…can be used in
conjunction with a mobile device app
Studies showed statistically significant increase in adherence for
children using monitoring device

16. New updates in GINA
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No longer recommends treatment with short acting beta-2 agonists
alone
Higher bronchodilator reversibility has been added as an independent
risk factor for exacerbation
Additional risk factors for developing persistent airflow limitation – pre-
term birth, low birth weight, greater infant weight gain
Step 5 treatment – Benaralizumab (monoclonal anti-IL5 receptor) has been
added to the existing treatment of severe eosinophilic asthma for
children >12 years
Treatment with low dose ICS for most patients with asthma even with
infrequent symptoms to reduce serious exacerbations
When stepping down from low dose ICS,add on LTRA may help

17. THANK YOU !!