‫מחלת אסטמה‪ :‬גישה וטיפול‬
‫ד"ר דוד שטרית‬
‫מנהל מערך הריאות‬
‫מרכז רפואי מאיר‬
‫כפר סבא‬
What is Asthma?
 Chronic disease of the airways that may cause




Wheezing
Breathlessness
Chest tightness
Nighttime or early morning coughing
 Episodes are usually associated with
widespread, but variable, airflow obstruction
within the lung
 Often reversible either spontaneously or with
treatment.
Pathology of Asthma
Asthma involves
inflammation of
the airways
Normal
Asthma
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and
funded by NIH/NHLBI, 1995
Benefits of ICS and LABA in asthma
Airway
inflammation
Smooth muscle
dysfunction
ICS
LABA
• Inflammatory cell
infiltration/activation
• Mucosal oedema
• Cellular proliferation
• Epithelial damage
• Airway remodelling, inc.
basement membrane
thickening
• Bronchoconstriction
• Airway
hyperresponsiveness
• Hyperplasia
• Inflammatory mediator
release
• Daily symptoms (e.g. cough, tightness of chest,
breathlessness)
• Reduced lung function
• Night-time awakenings
• Exacerbations
Adapted from Johnson M et al. Curr Allergy Clin Immunol 2002;15:16–22
‫לקראת טיפול‬
‫• טיפול יקבע תמיד על סמך‪:‬‬
‫ חומרת המחלה (ע"פ תפקודי ריאות)‬‫‪ -‬מידת השליטה במצב הנשימתי (אנמנזה מדוקדקת)‬
‫זכרו‪ :‬תלונות החולה אינן תמיד משקפות את חומרת מחלתו!‬
‫• אין לבסס חומרת או יציבות המחלה רק ע"ס נתוני בדיקה גופנית‪.‬‬
GINA : Levels of asthma control
Characteristic
Controlled
(all of the
following)
Partly controlled
(any measure present in
any week)
Daytime symptoms
None (≤2/week)
>2/week
Limitations of
activities
None
Any
Nocturnal symptoms/
awakening
None
Any
Need for reliever/
rescue treatment
None (≤2/week)
>2/week
Lung function
(PEF or FEV1)
Normal
<80% predicted or
personal best (if known)
Exacerbations
None
≥1/year*
*Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
†By definition, an exacerbation in any week makes that an uncontrolled asthma week
GINA 2006 (www.ginasthama.org)
Uncontrolled
Three or more
features of
partly controlled
asthma present
in any week
One in any
week†
‫מהי צריכה גבוהה מדי של‬
‫תרופות להקלה מיידית?‬
‫‪GINA 2009‬‬
‫האם אנחנו מצליחים להשיג שליטה טובה‬
‫על מחלת האסתמה ?‬
‫‪ 1‬מיתוך ‪ 3‬חולים משתמש‬
‫במשאף מקל לפחות פעם ביום‬
‫‪Prieto L et al. J Asthma 2007:44:461-467.‬‬
‫שימוש יתר במשאף מקל גורם לחולה‬
‫שלך להתפשר על איכות החיים‬
‫ביקורי יתר‬
‫במרפאה‬
‫הגבלה‬
‫במאמץ‬
‫חוסר יעילות‬
‫הגבלה בפעילות‬
‫חברתית‬
‫איבוד ימי‬
‫עבודה‬
‫התעורריות‬
‫בלילה‬
Reducing Exposure to
Environmental Tobacco Smoke
Evidence suggests an association
between environmental tobacco
smoke exposure and exacerbations
of asthma among school-aged,
older children, and adults.
Asthma Management
Asthma Medications
 Bronchodilators (Sympathomimetics)
 Bronchodilators (Anticholinergics)
 Inhaled Corticosteroids
 Leukotriene Receptor Antagonists
 Biologic Response Modifiers (Monoclonal
Antibodies)
‫מקומה של האחות בטיפול באסטמה‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫לוודא האם החולה מאוזן‬
‫האם נוטל טיפול מניעתי כפי שהומלץ?‬
‫מתי לפנות לרופא?‬
‫כיצד לנהל אורח חיים מתאים ולהימנע מהחמרות‬
‫‪ ‬מזג אויר‬
‫‪ ‬אלרגנים וזיהום אויר‬
‫‪ ‬כושר גופני‬
‫‪ ‬חיסונים במועד‬
Medications to Treat Asthma
 Medications come
in several forms.
 Two major
categories of
medications are:
 Long-term control
 Quick relief
Medications to Treat Asthma:
Quick-Relief
 Used in acute episodes
 Generally short-acting
beta2agonists or
anticholinergic
Medications to Treat Asthma:
Long-Term Control
 Taken daily over a long period of time
 Used to reduce inflammation, relax airway muscles,
and improve symptoms and lung function
 Inhaled corticosteroids
 Long-acting beta2-agonists
 Leukotriene modifiers
Bronchodilators (Sympathomimetics)
 Salmeterol
 Albuterol
 Terbutaline
Leukotriene modifiers antagonist
 Improves lung function and diminishes
symptoms & need for short-acting beta2
agonists
 Studies in mild-moderate asthma showing
modest improvements
 Alternative to low-dose inhaled steroids for pts.
with mild persistent asthm
Critera for Anti IG-E treatment
 Severe asthma despite step 4 GINA treatment
 Non smoking
 Allergic asthma
 Ig- E total level between 30-1500 unit
 Needs for systemic steroids in 2 asthma exacerbations in the
last year
 Relative contra indications for systemic steroids.
Rationale for anti-IgE therapy
Xolair® (anti-IgE) stops IgE binding to effector cells
Allergen
IgE
synthesis
Mast cell
degranulation
Inflammatory
mediators
Clinical symptoms
Allergic rhinitis
Mechanism
Asthma
Food
allergy
Treatment
Allergen
avoidance
Hyposensitization
Mast-cell
stabilization:
cromones,
isoprenaline
Mediator
antagonists:
antihistamines,
antileukotrienes
Late-phase
inhibitors:
steroids
Adapted from Roitt J. Essential Immunology 1994
Atopic
eczema,
urticaria
Humanized
monoclonal anti-IgE antibody: Xolair
IgE
Xolair
C3
Updated Dosing Table
Monitoring to maintain Control
 1-3 months interval
 Lowest step and dose of treatment
 After asthma exacerbation: 2-4 weeks
 Asses the status according to the following questions
 Assess the current treatment, compliance
Special considerations in managing
asthma
 Pregnancy
 Obesity: weight loss improves asthma control, lung function





and reduces medication needs
Surgery: Steroids if FEV1 is less than 80% of the pt personal
best.
Rhinitis, Sinusitis and nasal polyps.
Respiratory infections
GERD: More common in asthma. PPI fail to improve asthma
control
Aspirin or NSAIDS induced asthma: 28%
‫רוב חולי האסתמה סובלים גם‬
‫מריניתיס על רקע אלרגי‬
Up to 80%
of all asthmatic patients have allergic rhinitis
All asthmatic patients
Adapted from Bousquet J et al. J Allergy Clin Immunol. 2001;108(suppl 5):S147–S334;
Sibbald B, Rink E. Thorax. 1991;46:895–901; Leynaert B et al. J Allergy Clin Immunol. 1999;104:301–304; Brydon MJ. Asthma J. 1996:29–32.
‫הטיפול האפשרי‬
‫• ספריי לאף לנזלת אלרגית כדוגמאת פלקסונייז או ‪:Avamys‬‬
‫יעיל בכל שבעת הסיפטומים הנזליים והעיניים‪,‬‬
‫פעם ביום‬
‫י"ג‪/‬אדר‪/‬תשע"ב‬
‫‪30‬‬