1995 Definition of NHLBI

• Asthma is a chronic inflammatorydisorder of the

airways in which many cells play a role
especially mast cells, eosinophils and T
lymphocytes. In susceptible individuals, this
inflammation causes symptoms which are
associated with widespread but variable
airflow obstructionthat is often reversible
either spontaneously or with treatment and
causes an increase in airway
hyperresponsiveness to a variety of stimuli
Incidence of Bronchial Disorders
ChronicBronchitis
Asthma
Emphysema

7.9
8 7.2

4
2.1
2

0
NumberofPts. (Millions)
 Asthma’s
Asthma’s Impact
Impact 2000
2000
q20.3
q 20.3 million
million currently
currently diagnosed
diagnosed
q10.4
q 10.4 million
million outpatient
outpatient visits
visits
q1.8
q 1.8 million
million ER
ER visits
visits
q465,000
q 465,000 hospitalizations
hospitalizations
q4,487
q 4,487 deaths
deaths
qTotal
q Total cost
cost $12.7
$12.7 billion
billion
q
q

Source:
Source: CDC
CDC Center
Center for
for Health
Health Statistics
Statistics
Change
Change In
In Number
Number Of
Of Persons
Persons With
With Asthma
Asthma
By
By Race
Race MMWR 3/2002

1-
1- 6X
6X

12 71%
71%

38%
38%
4
Other
Black
0
million
million 1980 1999 W hite
Race And Asthma Outcomes 1999

ER v
(per 1

Whites (MMWR)
(MMWR)
5
 Distribution
Distribution of
of Asthma
Asthma by
by Race
Race
US
US v.v. NYC
NYC
10.4 million 1 million

100%

80%
Asian
60% Hispanic
Other
40% White
Black
20%

0%
US NYC

Hispanics
Hispanics and
and Asians
Asians represent
represent 42%
42% of
of NYC
NYC asthmatics
asthmatics vv 7%
7% for
for US
US
• The mother of a 16 year old asthmatic boy
wants to know the likelihood of her son
outgrowing asthma. Which of the
following risk factors is the best
predictor of persisting asthma?
• a) unstable asthma
• b) age of onset
• c) symptoms of atopy
• d) symptoms of exercise induced asthma
 Predictors of poor outcome in
childhood asthma
•
• more severe and persistent symptoms
• high airway hypersensitivity
• male gender but not age of onset
• eczema but not atopy
 Epidemiology Of Asthma
• 1-5% incidence
• 50% of asthmatics present after age 15
• 50%-75% who present in childhood become
asymptomatic by adulthood
• 3% fatality rate (80% are over 30 years of
age)

 Population Trends
• Death is rare but preventable
• A twofold increase in mortality 1975 -1985
 Risk Factors for Developing
Asthma
• Strong factors
– family history of atopy (3x)
– house dust mites,cat
dander,cockroaches,alternaria
• Weak factors
– male,low birth weight,prematurity, parental
smokers, high salt diet
• The role of infection on Th1 v Th2 cells
–
Pathophysiology
Pathophysiology cont’d
 Mechanisms of Airway
Obstruction
• Bronchial smooth muscle contraction
• Airway inflammation and mucosal edema
• Increased and abnormally viscous mucus
• Increased collapsibility of airways
(emphysema)
 Initial Assessment and
Diagnosis of Asthma
■ Determine that:
– Patient has history or presence of
episodic symptoms of airflow
obstruction
– Airflow obstruction is at least partially
reversible
– Alternative diagnoses are excluded
 Clinical Features
 Asthma COPD Heart Disease

– wheeze 90 78 28
– tightness 90 75 45
– SOB 90 75 45
– VariantAsthma approximately 30 to 50% of patients
with chronic cough have asthma, especially children

•
–
 Initial Assessment and
Diagnosis of Asthma (continued)
Is airflow obstruction at least partially
reversible?

■ Use spirometry to establish airflow

obstruction:
– FEV1 < 80% predicted;
– FEV1/FVC <75% or below the lower limit of
normal
■ Use spirometry to establish reversibility:
– FEV1 increases >12% and at least 200 mL
after using a short-acting inhaled beta2-
agonist
–
 Volume Time curve

FET100%

5
Volume(liters)

FEV1
FVC

1 6
Time (Seconds)
Normal Flow - Volume Curve

T RV
L
C
Spirometry
 Normal Flow Volume Loop

FEV1/FVC>75%
 Mild and Severe Obstruction
FEV1/FVC<50% (ratio
FEV1/FVC<75%and >65
may normalize if RV
increased)
Obstructive Pattern
• a 32 year old female presents with
symptoms of exercise induced dyspnea.
She reports cough and dyspnea occurring
at rest and arousing her from sleep. Her
spirogram and physical exam are normal.
You suspect asthma. What has the
greatest specificity in diagnosing asthma?
• a) response to methacholine challenge
• b) measurement of diurnal variation in
PEFR
• c) subjective response to B agonist
• d) high total IgE
• Bronchial 

hyperresponsiveness –
can be seen in
which of the –
following? –
– COPD – CHF
– Cystic Fibrosis – Sarcoidosis
– Allergic Rhinitis – post-ARDS
– Post viral URI – Drowning
 Initial Assessment and
Diagnosis of Asthma (continued)

Are alternative diagnoses excluded?



■ Vocal cord dysfunction, vascular rings,

foreign bodies, other pulmonary disease
■ PE
■ CHF
■ Carcinoid Syndrome
■ Systemic mastocytosis
■
 Classification of Asthma Severity:
Clinical Features Before Treatment
 Days With Nights With PEF or
PEF
 Symptoms Symptoms FEV1
variability
 Step 4 Continuous Frequent ≤ 60% >30%
Severe
Persistent

 Step 3 Daily ≥ 5/month >60%-<80% >30%

Moderate
Persistent

 Step 2 3-6/week 3-4/month ≥ 80% 20-30%

Mild
Persistent

 Step 1 ≤ 2/week ≤ 2/month ≥ 80% <20%

Mild
Intermittent

Footnote: The patient’s step is determined by the most severe feature.

 Goals of Asthma Therapy

■ Prevent chronic and troublesome

symptoms
■ Maintain (near-) “normal” pulmonary
function
■ Maintain normal activity levels
(including exercise and other physical
activity)
 Component 2:
Control of Factors
Contributing to Asthma Severity
■ Assess exposure and sensitivity to:
■ Inhalant allergens (dust mites,
cockroaches)
■ Occupational exposures ( detect patterns)
■ Irritants:
■ Indoor air (including tobacco smoke)
■ Air pollution
 Significant Inhalant
Allergens: Additional
Considerations
■ Air conditioning allows windows to remain
closed and reduces indoor humidity.
■ Humidifiers and evaporative coolers are
not recommended.
 Component 2:
Control of Factors
Contributing to Asthma Severity
(continued)

■ Assess contribution of other factors:

– Rhinitis/sinusitis
– Gastroesophageal reflux
– Drugs (NSAIDs, beta-blockers)
– Viral respiratory infections
– Sulfite sensitivity
 Overview of
Asthma Medications
■ Daily: Long-Term Control
– Corticosteroids (inhaled and systemic)
– Cromolyn/nedocromil
– Long-acting beta2-agonists
– Methylxanthines
– Leukotriene modifiers
 Overview of
Asthma Medications (continued)
■ As-needed: Quick Relief
– Short-acting beta2-agonists
– Anticholinergics
– Systemic corticosteroids
 Stepwise Approach to Therapy for
Adults and Children >Age 5:
Maintaining Control
STEP 4 ■ Step down
Multiple long-term-control if
medications, include possible
oral corticosteroids ■ Step up if
STEP 3 necessary
> 1 Long-term-control ■ Patient
medications
education
STEP 2 and
1 Long-term-control environmenta
medication:
anti-inflammatory l control at
every step
STEP 1 ■ Recommend
Quick-relief medication: PRN referral to
specialist at
Step 4;
 Emergency Department and
Hospital Management:
Brief History and Functional
Assessment
(after treatment is initiated)
■ Time of onset and cause of exacerbation
■ Severity of symptoms, especially compared
to previous attacks
■ All current medications and time of last
dose
■ Measure FEV1 or PEFR
 Emergency Department and
Hospital Management:
Brief Physical Exam
■ Assess severity: Alertness, distress, accessory
muscle use, tachycardia, tachypnea, pulsus
paradoxus, cyanosis
■ Identify complications (e.g., pneumonia,
pneumothorax, pneumomediastinum)
■ Identify diseases that affect asthma
(otitis, rhinitis, sinusitis)
■ Rule out upper-airway obstruction
 Emergency Department and
Hospital Management:
Laboratory Assessment
■ Consider ABG in patients with suspected
hypoventilation, severe distress, or with FEV1
or PEF <30% predicted after initial treatment
■ CBC may be appropriate in patients with fever or
purulent sputum
■ Serum theophylline concentration
■ Serum electrolytes, chest x-ray, ECG in
special circumstances
Illustrative Examples of Arterial Blood
Gas Data in Asthmatic Patients
pO2 pCO2 pH A-a
Normal 95 40 7.40 4
Asthma I 85 40 7.40 14
II 95 30 7.50 17
III 72 28 7.52 43
IV (a) 55 38 7.42 47
IV (b) 40 52 7.28 44
IV (c) 160 58 7.22
 Emergency Department
and Hospital Management:
Initial Treatment (continued)
FEV1 or PEF <50%


■ Oxygen to achieve O2 saturation is >90%

■ Inhaled high-dose beta2-agonist and
anticholinergic by nebulization every 20
minutes or continuously
for 1 hour
■ Oral corticosteroid
■ Repeat assessment (Sx, physical exam, PEF,
O2 saturation, other tests as needed)
Emergency Department and
Hospital Management:
Good Response
•FEV1 or PEF >70%
•Response sustained 60 minutes after last
treatment
•No distress
•Physical exam: normal

•Discharge Home
Emergency Department and
Hospital Management:
Incomplete Response

•FEV1 or PEF >50% but <70%

•Mild-to-moderate symptoms

•Individualized decision re:

hospitalization
Emergency Department and
Hospital Management:
Poor Response
•FEV1 or PEF <50%
•PCO2 >42 mm Hg
•Physical exam: symptoms severe,
drowsiness, confusion

•Admit to hospital intensive care

 Mechanisms of Airway
Obstruction
• Bronchial smooth muscle contraction
• Airway inflammation and mucosal edema
• Increased and abnormally viscous mucus
• Increased collapsibility of airways
(emphysema)