ASTHMA

Presentation by: Dr. Zunaira Nawaz

Dr. Nida Shafique
Topic Outline

 Definition
 Etiology and Pathophysiology
 Clinical Features
 Diagnosis
 Management of Chronic Stable Asthma
 Management of Asthma Exacerbation
 Important Drugs
 Counselling
 Discharge Criteria of Patients
Definition

 Asthma  is a chronic inflammatory condition of

the airways characterized by variable and
recurring symptoms, reversible airflow
obstruction, and bronchospasm
Aetiology

 There are two major factors involved in the

development of asthma:
 Atopy: this is the term used in individuals who readily
develop antibodies of IgE class against common
environmental antigens such as the house dust mite, grass
pollen and fungal spores( Aspergillus fumigatus). Genetic
and enviromental factors affect serum IgE levels.
 Increased responsiveness of the airways of the lung to
stimuli such as inhaled histamine and methacholine.
Pathophysiology

 The primary abnormality in asthma is narrowing

of the airway which is due to:
 Smooth muscle contraction
 Thickening of the airway wall by cellular infiltration and
inflammation
 The presence of secretions within the airway lumen
Symptoms of Asthma

 Wheeze
 Cough
 Chest tightness
 Dyspnea
In asthma these symptoms tend to be
intermittent, worse at night and provoked by
triggers.
Differential Diagnosis of Wheeze

 f
Precipitating factors

 Viral infections
 Cold air
 Exercise
 Emotion
 Irritant dusts
 Vapours and fumes( cigarette smoke, perfume, exhaust fumes)
 Drugs : NSAIDS, aspirin, B- blockers
Common Occupations
associated with Asthma
 Veterinary medicine and animal handling
(allergens are mouse, rat and rabbit urine and
fur)
 Bakery (wheat, rye)
 Laundry work ( biological enzymes)
Associated diseases

 Acid reflux
 Polyarteritis nodosa
 Churg-strauss syndrome
 ABPA
Diagnosis of asthma

It is made on the basis of compatible clinical history

combined with the demonstration of variable airflow
obstruction:
 FEV1 > 15% (and 200ml) increase following
administration of a bronchodilator/trial of steroids.
 >20% diurnal variation on > 3days in a week for 2
weeks on PEF diary.
 FEV1 > 15% decrease after 6 mins of exercise.
 Histamine or methacholine challenge tests in
difficult cases.
 Skin-prick tests to identify allergens to which the
patient is sensitive.
 Chest x-ray: hyperinflation
 Aspergillus antibody titres in those with a marked
blood eosinophilia or transient shadowing on
chest xray.
 Move the marker to the bottom of the numbered
scale.
 Stand up straight.
 Take a deep breath. Fill your lungs all the way.
 Hold your breath while you place the mouthpiece in
your mouth, between your teeth. Close your lips
around it.
 Blow out as hard and fast as you can in a single
blow. Your first burst of air is the most important, so
blowing for a longer time will not affect your result.
 Write down the number you get. If you coughed or
did not do the steps right, do not write down the
number. Do it over again.
 Move the marker back to the bottom and repeat
these steps 2 more times. The highest of the 3
numbers is your peak flow number. Write it down in
your results log.
 MANAGEMENT OF
ASTHMA
Asthma is not curable but it
can be controlled!!!!
The effective management of asthma centres on
 Patient and family education
 Antismoking advice
 The avoidance of precipitating factors
 Specific drug treatment
Reducing Exposure to House Dust Mites

 Use bedding encasements

 Wash bed linens weekly
 Limit stuffed animals to those
that can be washed
 Reduce humidity level

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative
For Asthma Created and funded by NIH/NHLBI, 1995
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.

Evidence shows an association

between environmental tobacco
smoke exposure and asthma
development among pre-school
aged children.
Reducing Exposure to Pets

 People who are allergic to pets should not have

them in the house.

 At a minimum, do not allow pets in the bedroom.

Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit

mold growth may help prevent asthma exacerbations.
Other Asthma Triggers

Air pollution
Trees, grass, and weed pollen
The goals of asthma management

 Achieve and maintain control of symptoms

 Prevent asthma exacerbations
 Maintain pulmonary function as close to normal as
possible
 Avoid adverse effects from asthma medications
 Prevent development of irreversible airflow limitation
 Prevent asthma mortality
 Clinical classification of severity[8]

Use of short-acting
Severity in patients ≥ 12  %FEV1 of beta2 agonist for symptom
Symptom frequency Nighttime symptoms FEV1Variability
years of age [9] predicted control (not for prevention of
EIB)

Intermittent ≤2 per week ≤2 per month ≥80% <20% ≤2 days per week

>2 per week >2 days/week

Mild persistent 3-4 per month ≥80% 20–30%
but not daily but not daily

>1 per week but not

Moderate persistent Daily 60–80% >30% Daily
nightly

Frequent (often
Severe persistent Throughout the day <60% >30% Several times per day
7x/week)
Start treatment at any step considering the severity of disease.
STEP 1: mild intermittent asthma
Inhaled short acting B2 agonist(salbutamol) as required.
Mode of action: relax bronchial smooth muscles(by increasing cAMP) within
mins.
STEP 2: Regular preventive therapy(mild persistent)
Add inhaled steroid: beclometasone dipropionate or budesonide at 100-400 mcg
twice a day.. OR
Fluticasone at 50-200 mcg twice a day.
Mode of action: anti-inflammatory: red phospholipase A2 activity and expression
of COX2, therefore reducing leukotrienes( extremely potent
bronchoconstrictor) and inflammation.
STEP 3: Add on therapy(moderate persistent)
This is considered beyond an ICS dose of 800 mcg/day.
First choice add-on therapy: long acting B2 agonist(LABA) :
salmeterol 50mcg/ 12h or formoterol 12mcg/ 12h
Duration of action of atleast 12hrs.
Others that can be considered: leukotriene receptor
antagonist( montelukast 10mg PO daily)
OR
Theophylline: phosphodiesterase inhibitor, therefore
increasing cAMP n utimately leading to brochodilation.
STEP 4: Persistent poor control (severe
persistent)
 Increase inhaled steroid to 2000 mcg/day and/or
Addition of a fourth drug: oral therapy with
 LTRA: montelukast 10mg PO daily or
 Sustained release theophylline or
 Slow release B2 agonist
STEP 5 : Oral steroids (prednisolone)
Continuous or frequent use at the lowest dose
possible.
Oral steroids are used acutely as high dose, short
courses, eg prednisolone 40mg/24hr for 7 days
and longer term in lower doses eg 5-10 mg/24hr.
If control is not achieved at any step, consider step
up but first review medication technique,
adherence and environmental control.
Consider step down if good symptom control for 3
or more months.
How to Use a Spray Inhaler

The health-care
provider should
evaluate inhaler
technique at each
visit.

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for
Asthma Created and funded by NIH/NHLBI
ACUTE SEVERE ASTHMA

Acute severe asthma is diagnosed when a patient

has severe progressive asthmatic symptoms
over a number of hours or days.
It is a medical emergency and must be recognized
treated immediately.
HOW TO EVALUATE ?

History Current exacerbation

 Previous asthma  Duration
 Baseline PEFR  Severity
 Steroid requirement  Potential
 ED visits and hospital  Precipitating Factors and
admissions medications used
 Previous need for
intubation a good
predictor of risk of death.
CLINICAL FEATURES

 SEVERE ATTACK:
 Inability to complete a sentence in one breath
 Respiratory rate of > or equal to 25 breaths /min
 Tachycardia > or equal to 110 beats/min
 PEFR <50% predicted or patient’s best
Life threatening attack
 silent chest, cyanosis or feeble respiratory effort
 Exhaustion, confusion or coma
 Bradycardia or hypotension
 PEFR< 30% of predicted or best
 Blood gas markers of a life threatening attack are
PaO2 <60 mmHg or SpO2 < 92% despite treatment
with oxygen
INVESTIGATIONS:
 PEF
 ABGs
 CXR
 CBC
 UCE
Management of acute severe
asthma
Start treatment immediately prior to investigation.
 Sit the patient up and give 40-60% of oxygen to
achieve oxygen saturation of atleast 92%
 Salbutamol 5mg or terbutaline 10mg via O2 driven
nebulizer.
 Hydrocortisone 100mg IV or 60mg orally
 No sedatives of any kind.
 Antibiotics if definite evidence of infection
Monitor in all patients:
 Arterial oxygen saturation by pulse oximetry
 Arterial blood gaeses only if PaO2 <92% or life
threatening features
 PEFR 30mins after starting treatment, and then before
and after B2 agonist treatment
 Consider repeat blood gases 2hrs after starting treatment
 Fluid intake, aim for 2.5- 3L /day, IV if necessary
 U & E daily
If improved-continue
 60% O2
 Prednisolone tablets- reduce from 60mg to 30mg
daily for atleast 5days until recovery
 Nebulized B2 agonist 4hrly
After 24hrs, consider
 Adding in high dose inhaled corticosteroid
 Change nebulized to inhaled B2 agonist
Discharge from hospital
 When PEFR >75% predicted or best with diurnal
variability <25%
 Been on discharge medication for 24hrs
 Had inhaler technique checked
 Own a peak expiratory flow meter and have
management plan
 Determine reason for exacerbation
Life threatening features present or poor response to
treatment
 60% O2
 Hydrocortisone 100mg 6hrly IV
 Repeat nebulized B2 agonist every 15-30mins
 Continuous nebulization at 5-10mg/hr
 Add nebulized ipratropium bromide 500mcg 4-6hrly
 Add single dose Magnesium sulphate 1.2-2gm over
20mis by IV infusion
Consider intravenous:
 Salbutamol: 5mg in 500ml N/S or 5% dextrose( i.e.
10mg/ml). Give loading dose of 250mcg (25ml) over
10mins and continue at 10-30 mcgs /min( 1-3ml/min)
 Aminophylline: loading dose of 5mg/kg over 20mins
and continue at 0.5mg/kg/hr. Monitor blood
concentrations daily if continued for 24hrs,
therapeutic range 10-20mg/l.
If poor response within 1hr transfer to ITU for
possible intubation and mechanical ventilation.
Once patient is improving
 Wean down and stop aminophylline over 12-24hrs
 Reduce nebulized salbutamol and switch to inhaled
Bagonist
 Initiate inhaled steroids and stop oral steroids if possible
 Continue to monitor PEF.
 Look for deterioration on reduced treatment and beware
early morning dips in PEF
 Look for the cause of acute exacerbation and admission.