Bronchial Asthma 2009.mansfans.com

الله الله بسم بسمالرحمن الرحمن الرحيمالرحيم

www.MansFans.comwww.MansFans.com

BRONCHIAL BRONCHIAL ASTHMAASTHMA

BYBYDR ESSAM EL-GAMALDR ESSAM EL-GAMAL

PROFESSOR OF CHEST DISEASESPROFESSOR OF CHEST DISEASESMANSOURA FACULTY OF MEDICINEMANSOURA FACULTY OF MEDICINE

20092009


DEFINITIONDEFINITION

Chronic inflammatoryChronic inflammatory disorder of the disorder of the airways in which many cells play a role airways in which many cells play a role including mast cells, eosinophils and T-including mast cells, eosinophils and T-lymphocytes. lymphocytes.

Chronic inflammation is associated Chronic inflammation is associated with :with :

- - Airway hyperresponsivenessAirway hyperresponsiveness that that → → recurrent recurrent episodes of wheezing, breathlessness, chest episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night tightness, and coughing, particularly at night or in the early morning. or in the early morning.

- Widespread, but variable, - Widespread, but variable, airflow obstructionairflow obstruction within the lung that is often reversible either within the lung that is often reversible either spontaneously or with treatment.spontaneously or with treatment.

Asthma

Airway inflammation

Asthma is a chronic inflammatory disorder associated with BHR + widespread variable AWO.

AWOBHR


Asthma TriggersAsthma Triggers: :

Host FactorsHost Factors GeneticGenetic - Atopy- Atopy - BHR - BHR GenderGender ObesityObesity

Host FactorsHost Factors GeneticGenetic - Atopy- Atopy - BHR - BHR GenderGender ObesityObesity

Environmental Factors . Allergens (indoor, outdoor). . Air Pollution with irritants. . Occupational sensitizers. . Tobacco smoke. . RT Infections. . Diet.

Environmental Factors . Allergens (indoor, outdoor). . Air Pollution with irritants. . Occupational sensitizers. . Tobacco smoke. . RT Infections. . Diet.


ATOPYATOPY allergic hypersensitivity affecting allergic hypersensitivity affecting

parts of the body not in direct parts of the body not in direct contact with the allergen. contact with the allergen. Associated with :Associated with :

- a strong hereditary component.- a strong hereditary component. - elevated serum levels of total and - elevated serum levels of total and

allergen-specific IgE, → positive allergen-specific IgE, → positive skin-prick tests to common skin-prick tests to common allergens.allergens.

Includes atopic dermatitis, allergic Includes atopic dermatitis, allergic rhinitis, conjunctivitis, and asthma.rhinitis, conjunctivitis, and asthma.

Common Allergens & Irritants :

AllergensAllergens•Food.Food.•Pollen / Pollen /

Molds.Molds.•Animals/Pets.Animals/Pets.•Cockroaches.Cockroaches.•Dust.Dust.

IrritantsIrritants•Secondhand Secondhand

sk.sk.•Strong odors.Strong odors.•Ozone.Ozone.•Chem Chem

compoundscompoundswww.MansFans.comwww.MansFans.com

Asthma triggersAsthma triggers

Allergens

Viruses andother pathogens

StressDrugs (aspirin)SmokingExercise

Occupationalchemicals

PETS

Is it AsthmaIs it Asthma??Is it AsthmaIs it Asthma??

Recurrent episodes of wheezes.Recurrent episodes of wheezes. Recurrent cough at night.Recurrent cough at night. Wheeze or cough after exercise.Wheeze or cough after exercise. Wheeze, cough or chest tightness after Wheeze, cough or chest tightness after

exposure to airborne allergens or exposure to airborne allergens or pollutants.pollutants.

Colds “go to the chest” or take > 10 Colds “go to the chest” or take > 10 days to cleardays to clear


PollenPollen

• GrassGrass عشبعشب , pine, pineصنوبرصنوبر , , oak trees. oak trees. بلوطبلوط

• Transported by wind Transported by wind and can get indoors and can get indoors during pollen season.during pollen season.

• Close windows during Close windows during pollen season.pollen season.

• Weather-strip doors and Weather-strip doors and windows.windows.

• Found everywhere, too Found everywhere, too small to be seen.small to be seen.

• Live in soft bedding, in Live in soft bedding, in warm, humid places.warm, humid places.

• Feed on dead skin Feed on dead skin cells.cells.

• Mites & mite droppings Mites & mite droppings can trigger asthma.can trigger asthma.

Dust MitesDust Mites

Pets/AnimalsPets/Animals

• Skin flakes, urine, and saliva of warm Skin flakes, urine, and saliva of warm blooded animals trigger asthma.blooded animals trigger asthma.

• Triggers remain inside for several Triggers remain inside for several Mns after an animal is removed.Mns after an animal is removed.

MoldsMolds

• A type of fungus.A type of fungus.• Grow on damp Grow on damp

surfaces by surfaces by releasing spores.releasing spores.

• Grow on organic Grow on organic materials: wood, materials: wood, drywall, carpet, drywall, carpet, foods, wallpaper. foods, wallpaper.


Other Indoor Triggers:Other Indoor Triggers:Household ProductsHousehold Products

• Vapors from cleaning Vapors from cleaning solvents paint, liquid solvents paint, liquid bleach, mothballs, glue.bleach, mothballs, glue.

• Spray deodorants, Spray deodorants, perfume.perfume.

• bleach, bleach, pesticidespesticides, oven , oven cleaners, aerosol spray cleaners, aerosol spray products.products.

Pathogenesis of Pathogenesis of AsthmaAsthma

Immunologic mechanism.Immunologic mechanism. Neural mechanism.Neural mechanism. Genetic mechanism.Genetic mechanism.


1) Immunologic Mechanism :1) Immunologic Mechanism :

Occur in atopic pts due to Occur in atopic pts due to Immediate R : Immediate R :

Ag/Ab R on the surface of MC → cell Ag/Ab R on the surface of MC → cell disruption & release of mediators disruption & release of mediators (histamine, bradykinin) → BC.(histamine, bradykinin) → BC.

Late R : Late R :

PAF & MBP → oedema & cell infiltratin PAF & MBP → oedema & cell infiltratin of br wall.of br wall.

MCP & eosinophils and lymphocytes : MCP & eosinophils and lymphocytes : play role in the inflam reaction in BA. play role in the inflam reaction in BA.

2) Neural Mechanism :2) Neural Mechanism :

.ANS plays a role in the control of .ANS plays a role in the control of airway contraction, relaxation and airway contraction, relaxation and secretions.secretions.

. Symp NS → BD.. Symp NS → BD.

. Parasymp NS → BC and . Parasymp NS → BC and secretions. secretions.

. NANC system →inhib innervation to . NANC system →inhib innervation to AW smooth Ms (BD), neurotransmitter AW smooth Ms (BD), neurotransmitter

is VIP.is VIP. 3) 3) Genetic Mechanism :Genetic Mechanism :

BA occurs in families, heredity may BA occurs in families, heredity may play a role in determination of BHR.play a role in determination of BHR.

Association of the Association of the ADAM33 gene with ADAM33 gene with asthma and BHR :asthma and BHR :

Genome scan (of 460 Caucasian Genome scan (of 460 Caucasian families) identified a locus on families) identified a locus on chromosome 20p13 (ADAM33).chromosome 20p13 (ADAM33).

ADAM proteins are membrane bound ADAM proteins are membrane bound metalloproteases with diverse metalloproteases with diverse funtcions; eg. Release of cytokines.funtcions; eg. Release of cytokines.

It will shed light on molecular pathway It will shed light on molecular pathway involved & new ttt strategies.involved & new ttt strategies.

PATHOGENESISPATHOGENESIS


Shedding ofShedding of airway epithelium. airway epithelium. Collagen deposition of in basal Collagen deposition of in basal

membrane. membrane. Hyperplasia of goblet cells.Hyperplasia of goblet cells. Hypertrophy of smooth muscles.Hypertrophy of smooth muscles. Inflammatory cell infiltration (N,E,L).Inflammatory cell infiltration (N,E,L).

Histologic Features In Histologic Features In AsthmaAsthma

What happens during an What happens during an asthma episodeasthma episode??

Airways narrow due to : Airways narrow due to :

. tightening of the ASM. tightening of the ASM

. swelling of inner lining.. swelling of inner lining.

. . mucous production. mucous production.


Asthma DiagnosisAsthma Diagnosis

History and patterns of symptoms.History and patterns of symptoms.

Measurements of lung function :Measurements of lung function :

- Spirometry- Spirometry

- Peak expiratory flow- Peak expiratory flow

Measurement of airway Measurement of airway responsiveness. responsiveness.

Measurements of allergic status to Measurements of allergic status to identify risk factors.identify risk factors.

History and patterns of symptoms.History and patterns of symptoms.

Measurements of lung function :Measurements of lung function :

- Spirometry- Spirometry

- Peak expiratory flow- Peak expiratory flow

Measurement of airway Measurement of airway responsiveness. responsiveness.

Measurements of allergic status to Measurements of allergic status to identify risk factors.identify risk factors.

C/P of Bronchial AsthmaC/P of Bronchial Asthma: :

Symptoms : recurrent attacks of :Symptoms : recurrent attacks of : Breathlessness and chest tightness.Breathlessness and chest tightness. Chest Wheezes.Chest Wheezes. Cough more at night.Cough more at night.

Signs : during asthma attacks :Signs : during asthma attacks : Tachycardia>120/min,tachpnea>30/min.Tachycardia>120/min,tachpnea>30/min. Pulsus paradoxus > 20 mm Hg.Pulsus paradoxus > 20 mm Hg. Cyanosis.Cyanosis. Inability to speak in sentences.Inability to speak in sentences. Use of accessory respiratory muscles.Use of accessory respiratory muscles. Chest wheezes or Silent chest.Chest wheezes or Silent chest.

Pulsus paradoxusPulsus paradoxus Definition : Definition : an exaggeration of normal variation in the an exaggeration of normal variation in the

pulse during respiration, in which the pulse pulse during respiration, in which the pulse becomes weaker as one inhales & stronger as becomes weaker as one inhales & stronger as one exhalesone exhales. .

Occurs in several conditions including :Occurs in several conditions including : asthma, COPD, cardiac tamponade, pericarditis, asthma, COPD, cardiac tamponade, pericarditis,

chronic sleep apnea and croup. chronic sleep apnea and croup.

Detection : Detection : by measuring variation of SBP with respiration : by measuring variation of SBP with respiration : . Normal SBP variation (with respiration) is . Normal SBP variation (with respiration) is

considered to be ≤10 mmHg. considered to be ≤10 mmHg. . Pulsus paradoxus is an inspiratory reduction in . Pulsus paradoxus is an inspiratory reduction in

systolic pressure > 10 mmHg. systolic pressure > 10 mmHg.

CLASSES OF ASTHMA CLASSES OF ASTHMA SEVERITYSEVERITY::

SeveritySeverityintermittentintermittentmild persistentmild persistent

SymptomSymptomss

> >once per weekonce per week ≥ ≥once per weekonce per week

but < once per daybut < once per day

EXBEXBbrief ( few hr: few days) brief ( few hr: few days) asymptomatic between asymptomatic between

EXBEXB

may affect activity may affect activity and sleepand sleep

NightNight

SymptomSymptomss

> >22 times per monthtimes per month > >22 times per monthtimes per month

FEV1FEV1

or PEFor PEF≥ ≥ 80% OPV, 80% OPV,

variability < 20%variability < 20% ≥ ≥80%80% OPVOPV,,

variability < 20%variability < 20%

CLASSES OF ASTHMA SEVERITY:CLASSES OF ASTHMA SEVERITY:

SeveritySeveritymoderate moderate persistentpersistent

severe severe persistentpersistent

SymptomsSymptoms daily use of daily use of SABA SABA

continuous; continuous; physical physical

activities limitedactivities limited

EXBEXBaffect activity & affect activity & sleepsleep

frequentfrequent

NightNight

SymptomsSymptoms

> > once per weekonce per week frequentfrequent

FEV1FEV1

or PEFor PEF > >60%60% to < 80% to < 80%

OPV variability > OPV variability > 30%30%

=> =>60%60% OPV OPV variability > 30%variability > 30%

Levels of Asthma Levels of Asthma ControlControl

CharacteristicCharacteristicControlledControlledPartly controlledPartly controlled(Any present in (Any present in

any wk)any wk)UncontrolledUncontrolled

Daytime Daytime symptomssymptoms

None ( None ( ≤≤/ wk)/ wk) > >twice / wktwice / wk

≥≥3 3 features of features of

partly partly controlled controlled asthma in asthma in any weekany week

Limitations of Limitations of activitiesactivities

NoneNoneAnyAny

Nocturnal Nocturnal symptoms / symptoms / awakeningawakening

NoneNoneAnyAny

Need for Need for rescue / rescue / “reliever” ttt“reliever” ttt

None (None (≤≤ / wk) / wk) > >twice /wktwice /wk

Lung function Lung function (PEF or FEV(PEF or FEV11))

NormalNormal < <80%80% OPV or OPV or

personal best on personal best on any dayany day

ExacerbationExacerbationNoneNone One or more / y 1 in any weekOne or more / y 1 in any week

Investigation In Investigation In Bronchial Asthma:Bronchial Asthma:

Pulmonary function tests.Pulmonary function tests. Chest X-ray.Chest X-ray. ABG.ABG. Serum IgE.Serum IgE. Detection of allergen.Detection of allergen. Sputum Exam. Sputum Exam. Others : CBC, ECG.Others : CBC, ECG.w

ww

.Man

sFan

s.co

m

ww

w.M

ansF

ans.

com

Pulmonary function Pulmonary function tests In Bronchial tests In Bronchial

AsthmaAsthma Obstructive Hypoventilation Obstructive Hypoventilation ::

• FEVFEV11 < 80% OPV & FEV < 80% OPV & FEV11//FVC < 65%. FVC < 65%.

• Coved pattern of F-V loop : Coved pattern of F-V loop : maximal maximal exp begins & ends at higher lung exp begins & ends at higher lung volumes & lower flow rates than volumes & lower flow rates than normal.normal.

ReversibilityReversibility of AWO of AWO:: FEVFEV11 ≥ 12% ( ≥ 12% ( 200 mLs) after 2 puffs 200 mLs) after 2 puffs

of SABA.of SABA.

Pulmonary function Pulmonary function tests In Bronchial tests In Bronchial

AsthmaAsthma PEFR Variability : PEFR Variability :

. Shows > 20% diff ( ) the highest & lowest . Shows > 20% diff ( ) the highest & lowest values with morning dipping.values with morning dipping.

. Used to monitor EXB : to assess their . Used to monitor EXB : to assess their severity and guide management decisions.severity and guide management decisions.

Bronchoprovocation Challenge Test :Bronchoprovocation Challenge Test :

. With methacholine histamine or exercise . With methacholine histamine or exercise in cases with normal spirometry.in cases with normal spirometry.

OBSTRUCTIVE & RESTRICTIVE OBSTRUCTIVE & RESTRICTIVE HYPOVENTILATIONHYPOVENTILATION

OBSTRUCTIVE OBSTRUCTIVE RESTRICTIVE RESTRICTIVE

FEV1/ FVC FEV1/ FVC RATIO RATIO Reduced Reduced Normal orNormal or ↑ ↑

LUNG LUNG VOLUMESVOLUMES

. FEV1 markedly. FEV1 markedly ↓ ↓

. . FVC decreased FVC decreased . VC normal or . VC normal or ↓ ↓

. FEV1 markedly . FEV1 markedly ↓ ↓ . . FVC FVC

markedly markedly ↓ ↓ . . VC moderatelyVC moderately ↓ ↓

F-V LOOPF-V LOOPcoved patterncoved pattern witch's hat witch's hat appearanceappearance


Peak Flow MeterPeak Flow MeterHow to use PEF meter:How to use PEF meter: Stand up or sit up straight. Stand up or sit up straight. Slide indicator to base of meter. Slide indicator to base of meter. Take in deep breath. Take in deep breath. Place mouthpiece in mouth and seal Place mouthpiece in mouth and seal

lips around it. lips around it. Blow out as hard and fast as you Blow out as hard and fast as you can (one quick blow). can (one quick blow). Repeat process 2 times more. Repeat process 2 times more. Select highest number of the 3 effortsSelect highest number of the 3 efforts. .

MANAGEMENT OF ASAMANAGEMENT OF ASA::

A F TE R 2 0 M INP E F R

> 7 0 % -----> D IS C H A R G E< 7 0 % ----> R E P E A T


> 7 0 % -----> D IS C H A R G E< 7 0 % ----> R E P E A T


> 7 0 % -----> D IS C H A R G E< 7 0 % -----> IV C S T

A E R O S O L TH E R A P Y


MANAGEMENT OF ASAMANAGEMENT OF ASA::

> 7 0 % -----> D IS C H A R G E< 7 0 % ------> A D M IT

4 0 - 7 0 %IV C S T

6 0 M IN ---> A E R O S O L

A D M IT TO H O S P ITA L

2 5 -4 0 %IV C S T

A D M IT TO IC U

< 2 5 %IV C S T

IN TU B A TIO NM V

P E F R < 7 0 %

Flow-volume curve Flow-volume curve variationsvariations

Flow-volume curves from Flow-volume curves from

(A) a healthy person.(A) a healthy person.

(B) severe obstruction (emphysema).(B) severe obstruction (emphysema).

(C) severe restriction (interstitial fibrosis). (C) severe restriction (interstitial fibrosis).

(D) upper airways obstruction (tracheal stenosis). (D) upper airways obstruction (tracheal stenosis).

(E) poor effort.(E) poor effort.

Investigation In Bronchial Investigation In Bronchial AsthmaAsthma::

CXR :CXR : . May show a cause or C/O of BA :. May show a cause or C/O of BA : pneumonia, pnx, collapse, # ribs.pneumonia, pnx, collapse, # ribs.

ABG :ABG : . For hypoxemia, hypercapnia and need of MV.. For hypoxemia, hypercapnia and need of MV. Total serum IgE :Total serum IgE : . . in cases with atopy. in cases with atopy. Detection of Allergen :Detection of Allergen : . Serum specific IgE, skin prick test, BPT using . Serum specific IgE, skin prick test, BPT using

inhaled allergens.inhaled allergens.

Investigation In Bronchial Investigation In Bronchial AsthmaAsthma::

Sputum Exam :Sputum Exam : . May show eosinophilia, Curchman spirals, . May show eosinophilia, Curchman spirals,

Charcot-Leyden crystals and Creola bodies.Charcot-Leyden crystals and Creola bodies. CBC : CBC : . Eosinophilia in allergic diseases, . Eosinophilia in allergic diseases,

Leucocytosis in infection.Leucocytosis in infection.


Curschmann's Curschmann's spiralsspirals::

Yellow-white wavy Yellow-white wavy long threads long threads represent bronchial represent bronchial castscasts composed of : composed of :

- shed epithelium. - shed epithelium.

- spiral aggregates of - spiral aggregates of eosinophils.eosinophils.

- mucus. - mucus.

in a fibril network. in a fibril network.

Charcot-Leyden Charcot-Leyden crystalscrystals

Breakdown Breakdown product of product of eosinophils.eosinophils.

Appear : Appear : slender and slender and pointed and pointed and stain purplishstain purplish--red in the red in the trichrome stain. trichrome stain.

Creola BodiesCreola Bodies: :

compact compact clumps or clumps or strips of strips of columnar columnar epithelial cells epithelial cells shed from the shed from the bronchus.bronchus.


Alternative causes of Alternative causes of recurrent wheezing (Other recurrent wheezing (Other

D. Dx)D. Dx)considered and excluded. These include:considered and excluded. These include:• • Chronic rhino-sinusitis.Chronic rhino-sinusitis.• • Recurrent viral lower RTI.Recurrent viral lower RTI.• • TB.TB.• • COPD.COPD.• • GERD.GERD.• • FB aspiration.FB aspiration.• • Primary ciliary dyskinesia syndrome.Primary ciliary dyskinesia syndrome.• • Cystic fibrosis. Cystic fibrosis. • • Congenital malformation causing narrowing Congenital malformation causing narrowing

of the intrathoracic airways.of the intrathoracic airways.• • Congenital HD.Congenital HD.• • Immune deficiency.Immune deficiency.

COMPLICATIONS OF ACUTE COMPLICATIONS OF ACUTE SEVERE ASTHMASEVERE ASTHMA

Pneumothorax, Pneumothorax, pneumomediastinum, pneumomediastinum, pneumopericardium, subcutaneous pneumopericardium, subcutaneous emphysema.emphysema.

ABPA. ABPA. Rib Fracture.Rib Fracture. Respiratory Failure.Respiratory Failure. tracheoesofageal fistula (with MV).tracheoesofageal fistula (with MV). Death.Death.

GINA GUIDELINES FORGINA GUIDELINES FORStepwise Approach to Stepwise Approach to

Therapy :Therapy :

G-IN-A : Global Initiative for G-IN-A : Global Initiative for Asthma ManagementAsthma Management


GINA GUIDELINES FORGINA GUIDELINES FORStepwise Approach to Therapy Stepwise Approach to Therapy

:: PRN : Quick Relievers : PRN : Quick Relievers :

iSABA : given PRNiSABA : given PRN Daily or increasing use indicates need for Daily or increasing use indicates need for

longlong--term control therapy.term control therapy. Intensity of ttt depends on severity of Intensity of ttt depends on severity of

EXB.EXB.

Daily : Long-term Control Therapy:Daily : Long-term Control Therapy:

ICS and other drugs in scheduleICS and other drugs in schedule NB : Step 1 Intermittent asthma : NB : Step 1 Intermittent asthma : no LTC.no LTC.

GINA GUIDELINES FORGINA GUIDELINES FORStepwise Approach to Therapy :Stepwise Approach to Therapy :

Daily LTCDaily LTCStep 2 Step 2 Mild Mild PersistentPersistent

ICS/LD OR Cromolyn OR nedocromil ICS/LD OR Cromolyn OR nedocromil OR SR–theo OR LTMOR SR–theo OR LTM

Step 3 Step 3

Moderate Moderate Persistent Persistent asthmaasthma

ICS/MD ORICS/MD OR ICS/LD-MD + iLABA (OR SR-theo)ICS/LD-MD + iLABA (OR SR-theo)

- If needed - If needed dose (ICS/HD, iLABA) dose (ICS/HD, iLABA)

- Consider refrral to a specialist- Consider refrral to a specialist

Step 4 Step 4

Severe Severe Persistent Persistent AsthmaAsthma

ICS/HD + all : ICS/HD + all : LABD:iLABA OR SR_theo OR oral LABD:iLABA OR SR_theo OR oral LABALABA Oral CT: long-term.Oral CT: long-term.

- Recommended refrral to a - Recommended refrral to a specialist.specialist.

Stepwise Approach to Stepwise Approach to Therapy Therapy : : Maintaining Maintaining

ControlControl Step down if Step down if

possiblepossible Step up if Step up if

necessarynecessary Pat education Pat education

& environm & environm control at every control at every stepstep

Recommend Recommend referral to referral to specialist atspecialist atStep 4; Step 4;

consider consider referral at Step referral at Step 33

STEP 4STEP 4Multiple longMultiple long--termterm--control control

medications, includemedications, includeoral corticosteroidsoral corticosteroids

STEP 3STEP 3 >> 1 1 Long Long--termterm--control control medicationsmedications

STEP 2STEP 211 Long Long--termterm--control control

medicationmedication : : antianti--inflammatoryinflammatory

STEP 1STEP 1

QuickQuick--relief medicationrelief medication: : PRNPRN

1) Daily Long1) Daily Long--Term Term Control : Control : Not neededNot needed

2) PRN Quick Relief2) PRN Quick Relief–iSABA : PRNiSABA : PRN– use, or use > use, or use >

2 2 // wk, may wk, may indicate need for indicate need for longlong--termterm--control control – Intensity of tttIntensity of ttt

depends on depends on severity of severity of EXBEXB

Step 1 Treatment Step 1 Treatment : : Mild IntermittentMild Intermittent

STEP 1STEP 1

Step 2 Treatment Step 2 Treatment : : Mild PersistentMild Persistent

1) Daily Long1) Daily Long--Term Term ControlControl

– AntiAnti--inflammatoryinflammatory ICS ICS ((low doselow dose) ) oror Cromolyn or Cromolyn or

nedocromil nedocromil OROR– SR theophylline SR theophylline ((to to

serum conc 5-15serum conc 5-15 mcgmcg//mLmL)) is an is an alternative but not alternative but not preferred.preferred.

– Leukotriene modifier Leukotriene modifier may be consideredmay be considered

STEP 2STEP 2

Step 2 Treatment Step 2 Treatment : : Mild PersistentMild Persistent

((continuedcontinued))

2) PRN Quick 2) PRN Quick ReliefRelief

iSABA : PRNiSABA : PRN Daily or Daily or increasing use increasing use indicates need indicates need forfor longlong--termterm--controlcontrol

Intensity of ttt Intensity of ttt depends on depends on severity of EXBseverity of EXB

STEP 2STEP 2


Step 3 Treatment Step 3 Treatment : : Moderate PersistentModerate Persistent

1) Daily Long1) Daily Long--Term ControlTerm Control ICS ICS ((medium dosemedium dose))OROR ICS ICS ((lowlow--toto--medium dosemedium dose) )

ANDAND LABA or SR theophylline.LABA or SR theophylline.IF NEEDED, increase toIF NEEDED, increase to:: ICSICS ((mediummedium--toto--high dosehigh dose) )

and LABA.and LABA.Consider referral to a Consider referral to a

specialistspecialist

STEP 3STEP 3

Step 3 Treatment Step 3 Treatment : : Moderate Persistent Moderate Persistent

((continuedcontinued))

PRN Quick ReliefPRN Quick Relief iSABA : PRNiSABA : PRN Daily or increasing use Daily or increasing use

indicate need for longindicate need for long--

termterm--control therapycontrol therapy Intensity of ttt depends Intensity of ttt depends

on severity of EXBon severity of EXB

STEP 3STEP 3

Step 4 Treatment Step 4 Treatment : : Severe PersistentSevere Persistent

1) Daily Long1) Daily Long--Term Term ControlControl

ICS ICS ((high dosehigh dose) ) ANDAND LongLong--acting acting

bronchodilatorbronchodilator– iLABA iLABA OROR– SR theophylline SR theophylline OROR– LABA tablets LABA tablets ANDAND

Long term Oral CSTLong term Oral CSTRecommend referral to Recommend referral to

a specialista specialist

STEP 4STEP 4


Step 4 Treatment Step 4 Treatment : : Severe PersistentSevere Persistent

(( continued continued))

2) PRN Quick Relief2) PRN Quick Relief iSABA : PRNiSABA : PRN Daily or increasing Daily or increasing

use indicates need use indicates need

for longfor long--term control term control

therapytherapy Intensity of ttt Intensity of ttt

depends on severity depends on severity

of of EXB.EXB.

STEP 4STEP 4

““those who care for the patients can be taught to those who care for the patients can be taught to manage cases well with what is availablemanage cases well with what is available”.”.

E ParryE Parry The Tropical Health & Education TrustThe Tropical Health & Education Trust LondonLondon

Thorax1997;52:589Thorax1997;52:589

Without actions asthma drugs are available only for rich patients and for animals in rich countries!

New Zealand. Sunday Star. TimesJanuary 4,2004Photo : Kevin Stent


Thank youThank youThank youThank you

New changes in asthma New changes in asthma medicationsmedications

Leukotriene modifiers now have a more Leukotriene modifiers now have a more prominent role as controller treatment in prominent role as controller treatment in asthma, particularly in adults.asthma, particularly in adults.

LABA alone are no longer presented as an LABA alone are no longer presented as an option for add- on treatment at any step of option for add- on treatment at any step of therapy, unless accompanied by ICS.therapy, unless accompanied by ICS.

Monotherapy with cromones is no longer Monotherapy with cromones is no longer given as an alternative to monotherapy with given as an alternative to monotherapy with a low dose of ICS in adults.a low dose of ICS in adults.

Some changes have been made to the Some changes have been made to the tables of equipotent daily doses of ICS for tables of equipotent daily doses of ICS for both children and adults.both children and adults.

How serious is it, as a health How serious is it, as a health problemproblem? ?

A very common AW disease.A very common AW disease. About 155 million individuals About 155 million individuals

worldwide are affected.worldwide are affected. Number one chronic illness Number one chronic illness

among children and young adultsamong children and young adults From 1979 to 1996, the no. of From 1979 to 1996, the no. of

children dying from asthma children dying from asthma increased 300%increased 300%

What is asthma ?What is asthma ?

Caused by hypersensitivity of airways Caused by hypersensitivity of airways to a number of triggersto a number of triggers

Dust-pollen-smoke-cold air-excerciseDust-pollen-smoke-cold air-excercise

The airways are obstructed leading to The airways are obstructed leading to difficulty in breathingdifficulty in breathing

Can lead to death in severe casesCan lead to death in severe cases Usually associated with atopy, Usually associated with atopy,

elevated IgE in serum and bronchialelevated IgE in serum and bronchial hyper- responsivenesshyper- responsiveness

ACUTE SEVERE ASTHMAACUTE SEVERE ASTHMA TERMINAL ASTHMATERMINAL ASTHMA

pt is alert, distressedpt is alert, distresseddrowsy, confuseddrowsy, confused

hot sweats, palehot sweats, palecold sweats, cyanosedcold sweats, cyanosed

wants to sit upwants to sit up

says few wordssays few wordswants to lie downwants to lie down

can not speakcan not speak

hyperinflation withhyperinflation with

insp & exp movementsinsp & exp movementshyperinflation withhyperinflation with

no expansionno expansion

audible wheezesaudible wheezessilent chestsilent chest

tachycard., P alternanstachycard., P alternansbradycar., no pulsusbradycar., no pulsus

FLOW-VOLUME LOOPFLOW-VOLUME LOOP

. . Normal Loop Normal Loop →→ rapid rise to the PEFR, rapid rise to the PEFR, followed by a nearly linear fall.followed by a nearly linear fall.

. Obstructive . Obstructive →→ maximal exp begins & maximal exp begins & ends at higher lung volumes and lower ends at higher lung volumes and lower flow rates than normal flow rates than normal →→ coved coved pattern.pattern.

. Restrictive . Restrictive →→ lung volumes & flow rates lung volumes & flow rates are are ↓↓ but the flow in relation to lung but the flow in relation to lung volume is > normal volume is > normal →→ witch's hat" witch's hat" appearanceappearance with a steep descending with a steep descending limb.limb.

CHARACTERISTICCHARACTERISTIC CONTROLLECONTROLLE

DD))All of the All of the

followingfollowing((

PARTLY PARTLY CONTROLLEDCONTROLLED

))Any measure Any measure present in any present in any

wkwk((

UNCONTROLLEUNCONTROLLEDD

Daytime Daytime SymptomsSymptoms

NoneNone ≤) ≤)twice /wktwice /wk((

≥ ≥twice /wktwice /wk

≥ ≥33 features/wkfeatures/wkof partly of partly

controlledcontrolledasthmaasthma

Need For Need For Reliever tttReliever ttt

NoneNone ≤) ≤)twice /wktwice /wk((

≥ ≥twice /wktwice /wk

Nocturnal Nocturnal SymptomsSymptoms

NoneNoneAnyAny

Limitations Of Limitations Of ActivityActivity

NonNonAnyAny

PFT (PEF or PFT (PEF or FEV1)FEV1)

NormalNormal > >80%80% OPVOPV

EXBEXBNoneNone ≥ ≥One /yearOne /yearOne in any wkOne in any wk

LEVELS OF ASTHMA CONTROL

AtopyAtopy Definition : an allergic hypersensitivity Definition : an allergic hypersensitivity

affecting parts of the body not in direct affecting parts of the body not in direct contact with the allergen. Associated contact with the allergen. Associated with :with :

1 - a strong hereditary component.1 - a strong hereditary component. 2 - elevated serum levels of total and 2 - elevated serum levels of total and

allergen-specific IgE, allergen-specific IgE, →→ positive skin- positive skin-prick tests to common allergens. prick tests to common allergens.

Includes atopic dermatitis, allergic Includes atopic dermatitis, allergic rhinitis, conjunctivitis, and asthma.rhinitis, conjunctivitis, and asthma.

Atopic syndrome can be fatal in serious Atopic syndrome can be fatal in serious allergic reactions such as anaphylaxis, allergic reactions such as anaphylaxis, due to reaction to food or environment.due to reaction to food or environment.

Pulsus paradoxusPulsus paradoxus

How to elicit the sign :How to elicit the sign :

Can be measured by listening to Can be measured by listening to KorotkoffKorotkoff sounds during blood pressure measurement sounds during blood pressure measurement -- slowly decrease cuff pressure to SBP level -- slowly decrease cuff pressure to SBP level where sounds are first heard during where sounds are first heard during expiration. Then, cuff pressure is slowly expiration. Then, cuff pressure is slowly lowered further until Korotkoff sounds are lowered further until Korotkoff sounds are heard heard throughoutthroughout the respiratory cycle, the respiratory cycle, during both inspiration and expiration. during both inspiration and expiration.

If the pressure difference between hearing If the pressure difference between hearing the first sounds and hearing them throughout the first sounds and hearing them throughout the respiratory cycle is > 10mmHg, it can be the respiratory cycle is > 10mmHg, it can be classified as pulsus paradoxus. classified as pulsus paradoxus.

INFLAMMATIONINFLAMMATIONAirflow Limitation

SYMPTOMSCough Wheeze

DyspnoeaTRIGGERS

Exercise, Cold Air

PathogenesisPathogenesis::Airway

Hyperresponsiveness

Genetic*

INDUCERSAllergens,Chemical sensitisers,Air pollutants, Virus infections

Mucous plug in asthmaMucous plug in asthma::

Additional TestsAdditional Tests

Reasons for Additional TestsReasons for Additional Tests The Tests The Tests

Patient has symptoms but spirometry is normal ornear normal.

– Assess diurnal variation of peak flow over 1 to 2 weeks.

– Refer to a specialist for bronchoprovocation with methacholine,

histamine, or exercise; negative test may helprule out asthma.

Suspect infection, large airway lesions, heartdisease, or obstruction by foreign object

– Chest x-ray

Suspect coexisting chronic obstructive pulmonarydisease, restrictive defect, or central airway

obstruction

– Additional pulmonary function studies– Diffusing capacity test

Suspect other factors contribute to asthma(These are not diagnostic tests for asthma.)

– Allergy tests—skin or in vitro– Nasal examination– Gastroesophageal reflux assessment

SevereSevere episode episode

SubcutaneousSubcutaneous emphysema emphysema ·Significant ·Significant reduction reduction of breath of breath

sounds suggesting mucus plugging sounds suggesting mucus plugging or pneumothorax.or pneumothorax.

··Pulsus paradoxusPulsus paradoxus greater than 20 greater than 20 mm Hgmm Hg

·Agitation·Agitation Unable to Unable to lie flatlie flat PEF after therapy PEF after therapy lessless than than 50%.50%.

Treatment: First-line Drugs

Oxygen to keep SaO2 > 92%

Inhaled Beta2 Agonists: Salbutamol (Albuterol)

MDI: 4-8 puffs (100 ug/puff) q15-20 min with spacer, increase by one puff q 30-60 sec

Wet Nebulizer: 2.5-5 mg (0.5-1 ml) in 2.5 mlnormal saline q15-20 min

CorticosteroidsOral: prednisone 40-60 mgIntravenous: methylprednisolone 125 mg bolus

then 120-180 mg/day in 3-4 divided doses for 48 hrs

Step 1: Initial Step 1: Initial AssessmentAssessment Vital Signs Vital Signs

Heart RateHeart Rate Respiratory RateRespiratory Rate Peak Expiratory Flow RatePeak Expiratory Flow Rate (PEF) or FEV1 (PEF) or FEV1 Oxygen SaturationOxygen Saturation

Respiratory Status Respiratory Status Lung auscultation Lung auscultation Assess accessory muscle use Assess accessory muscle use Chest X-RayChest X-Ray has low yield in acute exacerbations has low yield in acute exacerbations

Assessment if patient in extremisAssessment if patient in extremis Arterial Blood GasArterial Blood Gas

Step 2: Initial Step 2: Initial ManagementManagement Inhaled Inhaled Short-acting Beta AgonistShort-acting Beta Agonist ( (NebulizedNebulized

AlbuterolAlbuterol) )

One dose up to One dose up to every 20 minutesevery 20 minutes for one hour for one hour AnticholinergicAnticholinergic (Ipratropium bromide or (Ipratropium bromide or AtroventAtrovent))

Indication: FEV1 or PEF <50% of predicted (Severe) Indication: FEV1 or PEF <50% of predicted (Severe)

Add to Add to Nebulized AlbuterolNebulized Albuterol Systemic CorticosteroidSystemic Corticosteroid IV Indication : IV Indication :

Severe episode (FEV1 or PEF <50% predicted) Severe episode (FEV1 or PEF <50% predicted) No immediate response No immediate response

OxygenOxygen indication indication Oxygen SaturationOxygen Saturation <91% <91% Consider Additional measures for severe Consider Additional measures for severe

exacerbation exacerbation

Step 3: ReassessStep 3: Reassess Repeat measures in step 1Repeat measures in step 1

ModerateModerate episode ( PEF 60-80% of predicted ) episode ( PEF 60-80% of predicted ) Nebulized AlbuterolNebulized Albuterol hourly hourly Consider Consider Systemic CorticosteroidSystemic Corticosteroids s Continue management for 1-3 hours while Continue management for 1-3 hours while

improving improving SevereSevere episode ( PEF <60% predicted ) episode ( PEF <60% predicted )

Nebulized AlbuterolNebulized Albuterol hourly or continuous hourly or continuous Consider adding Consider adding ipratropriumipratroprium bromide to bromide to

nebulizer nebulizer Oxygen Oxygen Systemic CorticosteroidSystemic Corticosteroids s

Prednisone Prednisone 1-2 mg/kg/day qd-bid 1-2 mg/kg/day qd-bid Maximum: 40-60 mg/day for 5-10 days Maximum: 40-60 mg/day for 5-10 days No taperingNo tapering needed if use less than 2 weeks needed if use less than 2 weeks

Emergency Room Management ofEmergency Room Management of AsthmaAsthma

•O2 to keep Sat >91%O2 to keep Sat >91%,,• nebulized b2 agonists up to every 20 minnebulized b2 agonists up to every 20 min•Systemic steroids and Ipratropium in severe casesSystemic steroids and Ipratropium in severe cases

Good ResponsePEF > 70%

Partial Response

PEF 50-70%

Poor ResponsePEF <50%

Continue1-2 hrs

DischargeHome

Admit to theHospital

PEF >70%PEF <70%

Managing ExerciseManaging Exercise--Induced Induced Bronchospasm Bronchospasm ((EIBEIB) ) ((continuedcontinued))

Management StrategiesManagement Strategies• ShortShort--acting inhaled betaacting inhaled beta22--agonists used agonists used

shortly before exercise last 2 to 3 hoursshortly before exercise last 2 to 3 hours• Salmeterol may prevent EIB for 10 to 12 hoursSalmeterol may prevent EIB for 10 to 12 hours• Cromolyn and nedcromil are also acceptableCromolyn and nedcromil are also acceptable• A lengthy warmup period before exercise may A lengthy warmup period before exercise may

preclude medications for patients who can preclude medications for patients who can tolerate ittolerate it

• LongLong--termterm--control therapy, if appropriatecontrol therapy, if appropriate

Hospitalized patients:

1 mg / kg of prednisone equiv. / 6 – 12 hrs for 48 hrs or FEV1 or PEFR reaches 50 % of predicted or of baseline then decrease dose to 60-80 mg / d. to achieve PEF 70 %

ICS to be started at beginning of tapering

If patient discharged from ER : 40 mg x 5 d. + ICS

short courses:

0.5 – 1 mg / kg / d prednisone in a single or bid dose ( 40-60 mg / d for 5-10 days )

Bid regimen decreases side effects

1 more week of a reduced dose can be added

relatively little dose-related toxicity

( mood disturb. – increased appet. – loss of glucose control in DM – candidiasis – cough )

Longer courses :

for more protracted bouts of severe asthma

slower rate for tapering

( avoid exacerbations & adrenal suppression )

repeated efforts to decrease dose to min. needed

alternate days is preferred

Alternate days :

in severe persistent asthma

( high dose ICS )

Calcium and vit. D or Bisphosphonates

I.V.

methyl predn.

In ER:

125 mg stat decreases rate of return to er

In ward :

40-60 mg qid

INHALED CORTICOSTEROIDS

1st line therapy for persistent asthma

High concentration directly to site of inflammation

Therapeutic index of drugs greatly enhanced

leading to less side effects

Members:

beclomethasone triamcinolone

flunisolide budesonide

fluticasone mometasone

MDI

PROPER TECHNIQUE

INHALATION CHAMBER

DRUG POWDER INHALERS

NON – CFC PERPELLANT SYST.

NEBULIZERS

Dose : 400 – 1000 ug of beclomethasone dipropionate or

equivalent

Increase dose as necessary guided by:

symp. ( frequency of B2 agonists – signs of poorly

controlled asthma )

PEF

50-100 % till symp. Are controlled

In case of: severe symp. – night awakening –

PEFR > 65% of predicted give a short course of OCS

Decrease dose by 25 % / 2-3 months to reach

lowest dose to control symp.

Date post:	13-Nov-2014
Category:	Documents
Upload:	mans-fans
View:	855 times
Download:	1 times

Bronchial Asthma 2009.mansfans.com

Documents