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Bronchial Asthma

Definition
Epidemiology
Risk factors
Pathology &
pathogenesis
Diagnosis
Management
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Definition
A chronic inflammatory disorder of
the airways associated with airway
hyperresponsiveness that leads to
recurrent episodes of wheezing,
breathlessness, chest tightness, and
coughing. These episodes are
usually associated with reversible
airway obstruction.
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Epidemiology
Asthma is a problem worldwide, with an
estimated 300 million affected individuals
Prevalence increasing in many countries,
especially in children
A cause of a significant number of
preventable deaths
A major cause of school/work absence
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Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Factors Influencing the


Development and Expression of
Asthma
Host factors
Genetic
Obesity
Sex

Cont. Risk Factors


Environmental Factors
Allergens (Indoor and Outdoor)
Infections (RCV and Parainfluenza)
Hygiene hypothesis
Occupational sensitizers
Tobacco smoking
Air pollution
Diet (breast feeding, antioxidants, n-6 PUFA, 3-n PUFA)
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Pathology & Pathogenesis

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Asthma Inflammation: Cells and


Mediators

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Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and


Mediators

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Source: Peter J. Barnes,


MD

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Mechanisms: Asthma
Inflammation

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Source: Peter J. Barnes,

Diagnosis
History and physical examination
Pulmonary function tests
Other laboratory tests

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Questions to Consider in the


Diagnosis of Asthma

Recurrent attacks of wheezing?


Troublesome cough at night?
Wheeze or cough after exercise?
Wheeze or tightness after exposure to
allergens or pollutants?
Does the cold go to the chest or take
more than 10 days to clear?
Are symptoms improved by asthma
treatment?
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Pulmonary Function Tests


Spirometry
Peak expiratory flow rate
Airway responsiveness

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Pulmonary Function Tests


Spirometry:
improvement in FEV1 after
bronchodilator by 12% (or >200ml)
PEFR
improvement by 60ml (or 20%)
or diurnal variation of > 20%
Airway responsiveness
histamine, methacholine, exercise
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Typical Spirometric (FEV1)


Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)

2
3
4
Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements

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Measuring Airway
Responsiveness

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Laboratory Tests
Chest X-ray
Blood tests
Eosinophil count
IgE level
Skin tests
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Management of Asthma
Education and develop patient/doctor
partnership
Identify and reduce exposure to risk
factors
Pharmacotherapy of asthma
Assess, treat, and monitor asthma

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Pharmacotherapy of Asthma

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Controllers

Inhaled glucocorticoid
Long-acting inhaled 2-agonists
Leukotriene modifiers
Theophylline
Cromones
Anti-IgE
Systemic glucocorticoids

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Comparative Daily Dosages of ICS


(g)
Drug

Low

Medium High

Beclomethasone-CFC 200-500 500-1000

> 1000

Beclomethasone-HFA 100-250 250-500

>500

Budesonide-DPI

200-600 600-1000

>1000

Fluticasone

100-250 250-500

>500
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Relievers

Rapid- acting 2-agonists


Anticholinergics
Systemic glucocorticoids
Theophylline

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Factors Affecting Compliance


Route of drug administration (oral vs
inhaled)
Complexity of drug regimen
Side effects of medications
Support of family and health care
professionals

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Treatment Goals
Achieve and maintain control of symptoms
Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to
normal as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma
medications
Prevent asthma mortality
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What is Controlled Asthma?

Day time symptoms: non or twice /week


No limitations of activity
No nocturnal symptoms
Need for reliever : non or twice/week
Normal lung function
No exacerbations
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Classification of Asthma Severity


Stage

Symptoms Night
symptoms

PFT

Mild
intermittent

< 2/week

< 2/month

PEF / FEV1
N
PEF var. < 20%

Mild
persistent

> 2/week
not daily

> 2/ month

PEF / FEV1 N
PEF var. 20-30%

Moderate
persistent

Daily
symptoms

> 1/week

PEF/FEV1 60-80%
PEF var. > 30%

Severe
persistent

Cont.
symptoms

Frequent

PEF/FEV1 < 60%


PEF var. >35
30%

Levels of Asthma Control


Characteristic
Daytime symptoms
Limitations of
activities

Controlled
(All of the following)
None (2 or less /
week)

Partly controlled
(Any present in any
week)
More than
twice / week

None

Any

Nocturnal symptoms /
None
awakening

Any

Need for rescue /


reliever treatment

None (2 or less /
week)

Lung function
(PEF or FEV1)
Exacerbation

Normal
None

Uncontrolled

More than
twice / week

3 or more
features of
partly
controlled
asthma present
in any week

< 80% predicted or


personal best (if
known) on any day
One or more / year

1 in any week

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REDUCE

LEVEL OF CONTROL

TREATMENT OF ACTION
maintain and find lowest
controlling step

partly controlled

consider stepping up to
gain control
INCREASE

controlled

uncontrolled
exacerbation

REDUCE

step up until controlled


treat as exacerbation

INCREASE

TREATMENT STEPS

STEP

STEP

STEP

STEP

STEP

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Stepping Down Treatment


Review medications after 3-6 months of
stability and if stable reduce medications
by 25-50%

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Features of Acute Severe


Asthma

PEFR 33- 50% (<200 l/m)


Cant complete sentences in one breath
Respiratory rate > 25/min
Pulse rate > 110/min
Pulsus paradoxus
Use of accessory muscles of breathing
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Features of Life Threatening


Asthma
Risk factor for near fatal asthma
PEFR < 33% (<100 l/m)
Silent chest, cyanosis, or feeble
respiratory effort
Bradycardia or hypotension
Exhaustion, confusion, or coma
PaCO2 normal or increased, PaO2 < 60
mmHg, or low pH
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Management of Acute
Exacerbations
PEF
50-75%
Uncontrolled asthma

Oxygen saturation
Nebulized -2
agonist
Check PEF
>75%
Home
50-75% Home with
short course of
prednisolone
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Management of Acute
Exacerbations
PEF
< 50%
Acute severe asthma

Oxygen
Nebulized -2 agonist
Nebulized
ipratropium
Check PEF
> 50%
Home
< 50%
Admit
Systemic steroids
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Management of Acute
Exacerbations
PEF
< 33%
Life threatening
asthma

Admit to ICU
Oxygen
Nebulized -2
agonist and
ipratropium
Systemic steroids
Consider assisted
ventilation
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When to Discharge Patient Home ?


24 hours on home medications
Oral prednisolone
Inhaled corticosteroids
Inhaled long acting -2 agonist
Inhaled short acting -2 agonist
Early appointment with clinic (2 weeks)
PEF > 75% of predicted or personal best
PEF variability < 20%
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