BRONCHIAL BRONCHIAL ASTHMAASTHMA

YOUSEF ABDULLAH AL TURKIYOUSEF ABDULLAH AL TURKIMBBS,DPHC,ABFMMBBS,DPHC,ABFM

Associate ProfessorAssociate ProfessorConsultant Family MedicineConsultant Family Medicine

King Khalid University HospitalKing Khalid University HospitalCollege of MedicineCollege of Medicine

King Saud UniversityKing Saud University

CASE SCENARIOCASE SCENARIO

Khalid 14 years old come to the clinic c/o Khalid 14 years old come to the clinic c/o shortness of breath for one day duration.shortness of breath for one day duration.

He is a known asthmatic patient for more He is a known asthmatic patient for more than 8 years, he visited A/E frequently.than 8 years, he visited A/E frequently.

His school performance is below average, His school performance is below average, with frequent absence from school due to with frequent absence from school due to his illness.his illness.

HOW YOU WILL PROCEED HOW YOU WILL PROCEED DURING THIS DURING THIS CONSULTATION ?CONSULTATION ?

What are your objectives in caring What are your objectives in caring for bronchial asthma patient ? for bronchial asthma patient ?

Prevent troublesome Prevent troublesome symptoms night and symptoms night and dayday

Prevent serious Prevent serious attacksattacks

Require little or no Require little or no reliever medicationreliever medication

Have productive, Have productive, physical, physical, psychological, and psychological, and social active livessocial active lives

WHAT IS BRONCHIAL WHAT IS BRONCHIAL ASTHMA?ASTHMA?

Asthma is a Asthma is a CHRONIC INFLAMMATORYCHRONIC INFLAMMATORY disorder of the airways. disorder of the airways.

Chronically inflamed airways are hyper Chronically inflamed airways are hyper responsive;responsive;

they become obstructed and airflow is they become obstructed and airflow is limited by bronchoconstriction,mucus limited by bronchoconstriction,mucus plugs, and increased inflammation when plugs, and increased inflammation when airways are exposed to various risk airways are exposed to various risk factors. factors.

WHAT IS THE PREVALENCE IN WHAT IS THE PREVALENCE IN SAUDI ARABIA ?SAUDI ARABIA ?

The prevalence of asthma among The prevalence of asthma among school children in K.S.A ( AL Frayh, school children in K.S.A ( AL Frayh,

et al )et al ) RangeRange

4%-23% 4%-23% Riyadh Riyadh

10%10% JeddahJeddah

12%12%

What is the Pathophysiology?What is the Pathophysiology?

Trigger FactorTrigger Factor Mast cellMast cell Mediators : Mediators :

histamine,prostaglandin,leukotrienes,as histamine,prostaglandin,leukotrienes,as well as cytokines.well as cytokines.

Inflammatory cellsInflammatory cells Sustained Inflammatory responseSustained Inflammatory response Contraction of airway smooth muscles Contraction of airway smooth muscles

(Bronchoconstriction)(Bronchoconstriction)

Pathophysiology (Cont.)Pathophysiology (Cont.)

Airway wall swelling (mucosal edema)Airway wall swelling (mucosal edema) Airway hyper responsivenessAirway hyper responsiveness Chronic changesChronic changes Hypertrophy of the smooth muscles, Hypertrophy of the smooth muscles,

thickening of the basement membranethickening of the basement membrane Airway remodelingAirway remodeling There is good evidence that asthma occurs There is good evidence that asthma occurs

in families.in families.

What are the Triggering Factors?What are the Triggering Factors?

Domestic dust Domestic dust mitesmites

Air pollutionAir pollution Tobacco smokeTobacco smoke Occupational Occupational

irritantsirritants Cockroach Cockroach Animal with furAnimal with fur PollenPollen

Triggering Factors ( cont.)Triggering Factors ( cont.)

Respiratory (viral) Respiratory (viral) infectionsinfections

Chemical irritantsChemical irritants Strong emotional Strong emotional

expressionsexpressions Drugs ( aspirin, Drugs ( aspirin,

beta blockers)beta blockers)

CASE SCENARIOCASE SCENARIO

Ahmed 6 years old come to primary Ahmed 6 years old come to primary care clinic with his father c/o chronic care clinic with his father c/o chronic cough for the last 3 months, mainly cough for the last 3 months, mainly at night .at night .

How you will approach this How you will approach this patient?patient?

HOW TO DIAGNOSE BRONCHIAL HOW TO DIAGNOSE BRONCHIAL ASTHMA ?ASTHMA ?

Consultation skillConsultation skill Relevant HistoryRelevant History

-Symptom-Symptom

-history of allergic disease-history of allergic disease

-Family history -Family history

-Environmental history-Environmental history

-Exclusion of other medical -Exclusion of other medical conditioncondition

Diagnosis of B.A ( cont.)Diagnosis of B.A ( cont.)

Relevant physical examinationRelevant physical examination InvestigationInvestigation

Do you need to do investigation?Do you need to do investigation?

Why ?Why ? Follow upFollow up Medical recordMedical record Role of Peak Flow MeterRole of Peak Flow Meter

CLASSIFY ASTHMA CLASSIFY ASTHMA SEVERITYSEVERITY

Mild intermittent Asthma (step1)Mild intermittent Asthma (step1) Mild persistent Asthma (step2)Mild persistent Asthma (step2) Moderate persistent Asthma (step3)Moderate persistent Asthma (step3) Severe persistent Asthma (step4)Severe persistent Asthma (step4)

How to manage and control How to manage and control Bronchial AsthmaBronchial Asthma

Educate patients to develop a Educate patients to develop a partnership in asthma carepartnership in asthma care

Assess and monitor asthma severityAssess and monitor asthma severity Avoid exposure to trigger factorsAvoid exposure to trigger factors Establish individual medication plans Establish individual medication plans

for long term management in for long term management in children and adultschildren and adults

How to manage and control How to manage and control Bronchial Asthma ( cont.)Bronchial Asthma ( cont.)

Establish individual plans to manage Establish individual plans to manage asthma attacksasthma attacks

Provide regular follow up care. Provide regular follow up care.

Stepwise approach ( children)Stepwise approach ( children)

classificaticlassificationon

mild mild IntermitteIntermittentnt

Mild Mild persistentpersistent

Moderate Moderate persistentpersistent

Severe Severe persistentpersistent

Minor Minor symptomssymptoms

< 1/week< 1/week 1-3 /week1-3 /week 4-5/week4-5/week ContinuouContinuouss

exacerbatiexacerbation/ on/ nocturnalnocturnal

< 1/month< 1/month 1 /month1 /month 2-3/month2-3/month > 4 > 4 /month/month

PEF PEF between between attacksattacks

>80%>80% >80%>80% 60-80%60-80% < 60%< 60%

Step 1Step 1 Step 2Step 2 Step 3Step 3 Step 4Step 4

Stepwise approach ( adult)Stepwise approach ( adult)

classificaticlassificationon

mild mild IntermitteIntermittentnt

Mild Mild persistentpersistent

Moderate Moderate persistentpersistent

Severe Severe persistentpersistent

Minor Minor symptomssymptoms

< 2 /week < 2 /week 2-3 /week2-3 /week 4-5 /week4-5 /week ContinuouContinuouss

exacerbatiexacerbation/ on/ nocturnalnocturnal

< 2 < 2 /month/month

2-3 /month2-3 /month 4-5 /month4-5 /month > 5 > 5 /month/month

PEF PEF between between attacksattacks

>80%>80% >80%>80% 60-80%60-80% < 60%< 60%

Step 1Step 1 Step 2Step 2 Step 3Step 3 Step 4Step 4

Evidence Based approachEvidence Based approach

Clinical evidence Clinical evidence http://www.clinicalevidence.orghttp://www.clinicalevidence.org

Cochrane libraryCochrane library http://www.cochrane.org/http://www.cochrane.org/

Evidence Based approach Evidence Based approach (example)(example)

Clinical EvidenceClinical Evidence

۩۩ What are the effects of treatments for What are the effects of treatments for chronic asthma?chronic asthma?

۩۩ what are the effects of treatments what are the effects of treatments for acute asthma?for acute asthma?

- Beneficial- Beneficial

- Likely to be Beneficial- Likely to be Beneficial

- unknown effectiveness- unknown effectiveness

INTERNET SITEINTERNET SITE

Guidelines NHLBI/ WHO reportGuidelines NHLBI/ WHO report

http://www.ginasthma.comhttp://www.ginasthma.com

Cochrane Site:Cochrane Site:

http://www.cochrane.org/http://www.cochrane.org/ Clinical Evidence:Clinical Evidence:

http://www.clinicalevidence.orghttp://www.clinicalevidence.org

QUESTIONS ???? QUESTIONS ????

THANK YOU THANK YOU WITH MY BEST REGARDSWITH MY BEST REGARDS

PRACTICAL PRACTICAL GROUP (A)GROUP (A) - Simple clinical algorithm for - Simple clinical algorithm for

management of bronchial asthma management of bronchial asthma among among ADULT in PHC clinicADULT in PHC clinic

GROUP (B)GROUP (B) - Simple clinical algorithm for - Simple clinical algorithm for

management of bronchial asthma among management of bronchial asthma among CHILDREN in PHC clinicCHILDREN in PHC clinic

Group (c)Group (c) - Simple clinical algorithm for - Simple clinical algorithm for

management of bronchial asthma in management of bronchial asthma in EMERGENCYEMERGENCY

REFERENCES and FURTHER REFERENCES and FURTHER READINGSREADINGS

The National Scientific Committee of The National Scientific Committee of Bronchial Asthma in Saudi Arabia. The Bronchial Asthma in Saudi Arabia. The National Protocol for the management of National Protocol for the management of Asthma, fourth edition1424/2003.Asthma, fourth edition1424/2003.

National Heart, lung, and Blood Institute, National Heart, lung, and Blood Institute, National Institute of Health. WHO National Institute of Health. WHO workshop report. Global Strategy for workshop report. Global Strategy for Asthma Management and Asthma Management and Prevention,2002. Prevention,2002.