Asthma

Asthma

Prof. Sevda Özdoğan MD, Chest Diseases

DEFINITION

Asthma is a chronic inflammatory disorder of the airways that causes a bronchial hyperreactivity which leads to recurrent episodes of reversible airflow obstruction with wheesing, breathlesssness, chest tightness and coughing

Characteristics of the disease:Chronic inflammationBHRDiffuse reversibl airway obstruction

INFLAMATION

Bronchial hyperreactivity Airway wall remodeling

Airflow limitation

Symptoms

Genetic predisposition: Multiple genes, Risk in a child is 20-30% if one parent has asthma; 70% if both the parents have asthma

+ Environmental factors: High allergen exposure (dust mite, cat, dog, fungi etc); Passive smoking; Respiratory infections; air pollution; occupational exposure

Clinical signs and symptoms

Asthma can be diagnosed on the basis of symptomsEpisodic breathlessnessWheesingChest tightnessCough (sometimes thick sputum)Seasonal variability of symptomsFamily history of asthma or atopic disease

Physical examination

Normal (Does not exclude asthma!!)

Wheesing on oscultation(Dyspnea, wheesing, hyperinflation are more likely to be present

during symptomatic periods) Wheesing can be absent in severe asthma (silent

chest) Cyanosis Drowsiness Difficulty in speaking Tachicardia Hyperinflated chest Accesory muscle activation with intercostal recession

Diagnosis

Measurements of lung function (PFT)Spirometry (FEV1/FVC<75%)Peak expiratory flowReversibility test (early and late)PEF diurnal variation monitoringNonspecific bronchoprovocation tests

(PD20) (measurement of hyperreactivity)Simple exercise test (6 min)

Chest x-ray (important in differential diagnosis)

Sputum or nasal smear eosinophyls

Measurement of allergic statusSkin testingSpecific Ig E in serum(A positive test does not mean allergic asthma so

must be confirmed by history of exposure and attack)

Factors that precipitate asthma exacerbations (Triggers)

Allergens (indoor and outdoor) Respiratory infections (RSV, Influensa) Exercise and hyperventilation Cold air, weather changes Foods, additives and drugs Irritant gases (air polution, smoking) Extreme emotional expression Occupational agents Gastroesophageal reflux Chronic rhinosinusitis

Allergens

Drugs or agents associated with induction of bronchospasm

Acetylsalicylic acid NSAI Beta blockers Contrast agents Cocaine Heroin Dipyridamol Hydrocortisone

Beclomethasone inh Pentamidine inh Protamine Vinblastine Mitomycin IL-2

Different Diagnostic Groups

Asthma in Elderly (differentiation from cardiac asthma, drug effects, changes in the perception of symptoms, difficulty in performing PFT, false positive reversibility)

Occupational AsthmaCough variant asthmaExercise induced asthmaSamter syndromeAsthma in pregnancy

Treatment Goals in Asthma

Prevent asthma attacks Achieve and maintain control of symptoms Maintain pulmonary function as close to normal levels

as possible Maintain normal activity levels, including exercise

(Increase life quality) Avoid adverse effects of medication Prevent development of irreversibl airflow limitation Prevent asthma mortality

Treatment program

Educate patients to develop a partnership in asthma management

Assess and monitor asthma severityAvoid or control asthma triggersEstablish individual medication plansEstablish plans for managing

exacerbationsProvide regular follow-up care

Asthma medications

Controllers: Inhaled corticosteroids (systemic steroids)Long acting bronchodilators (beta agonist)Methylxantines (Theophyline)Leukotriene modifiersChromones

New drugs: Anti IgE (Omeluzimab)

Relievers: quick relief medicine or resque medicine Short acting beta2 agonistSystemic corticosteroidsTheophyllineAnticholinergics

Corticosteroids

The most effective antiinflamatory medications

İmproves lung functionDecreases airway hyperreactivityReduces symptomsReduces exacerbationsİmproves quality of life

Side effects of systemic (inhaled)steroids

Skin thinning (stria) Adrenal suppression Osteoporosis Arterial hypertension Diabetes Cataracts Glaucoma Obesity Muscle weakness

• Oropharyngeal candidiasis

• Dysphonia

• Occasional coughing

Inhaled forms

Drug is delivered directly to the targedQuick effectSmall dosesNegligable systemic absorbtionLess side effects

LABA

Formeterol, SalmeterolRelax airway smooth muscleDecrease vascular permeabilityEnhance mucosilier clearanceModulate mediator release from mast

cells and basophylsActivity persists for 12 hours

Combined Inh CS+LABA Improves symptom scores Improves lung functionDecreases exacerbations and resque

medicine useSide effects:

Cardiovascular stimulationSkeletal muscle tremorHypokalemia

Methylxantines (Theophylline)

Bronchodilator effect (8-12 mg/ml) related to phosphodiesterase inhibition)

Antiinflamatory effect (5-10 mg/ml) Used in add-on therapy (Stimulation of respiratory center, diuretic)

Side effects: Nausea, vomiting Tachycardia, arrhytmia Seizures, death (>20 mg/ml)

Leukotriene modifiers

Montelucast, Zafirlucast, ZileutonInhibit the effects of cysteinyl leucotriens

released from mast cells and eosinophyls

Used in add on therapy to reduce the CS dose in moderate and severe asthma

Chromones

Nedocromil sodiumSodium chromoglycateNonsteroidal anti-inflamatory drugsInhibit IgE mediated mediator releaseLess effective than corticosteroids

Specific Immunotherapy

Subcutaneus or sublingual administration of allergen extracts

Very limited indicationGreatest benefit in patients with allergic

rhinitis that has been unresponsive to conventional pharmacotherapy or specific environmental control

Short acting beta agonists

Salbutamol, terbutalineProvide rapid relief of symptomsDuration of action is 4-6 hours

Anticholinergics

Ipratropium bromide (short acting) Block the effect of acethylcoline released from

cholinergic nerves in the airways Less potent bronchodilators than beta agonists

in asthma Side effects:

Dryness of mouth, bitter taste Glacoma Uretral spasm

Classification of asthma Mild intermittent Mild persistent Moderate

persistentSevere persistent

Symptoms <2/week, only after exercise or allergen exposure

FEV1, PEF >80%

Variab <20%

Day time symptoms >2/week not everyday

Night symptoms >2/month

PEF>80%

Variab 20-30%

Everyday symptoms

Night symptoms >1/week

PEF 60-80%

variab>30%

Everyday symptoms

Frequent night symtoms

PEF<60% variab >30%

Short acting beta agonist when needed

Low dose inh steroid/

Chromones/

Leucotriene modifiers

Low dose inh CS+LABA or CS+Theophyline

Moderate or High dose CS+LABA

Combination: (Theophylline, Oral CS)

Anti Ig E

Asthma out of control

Check: Imcompliance to treatment!!Exposure to precipitating factor?Respiratory Infection?GERD?Psychologic stress?

Breathlesness

Speaking

Agitation

Accesory muscle

activity

Wheesing

Respir Rate

Pulse

Pulsus paradoksus

PEF

PaO2

PaCO2

SaO2

Oscultation

Mild attackWalking

Sentences

-

-

Mild

< 20

< 100

< 10 mmHg

> %80

Normal

< 45 mmHg

> %95

End

ekspiratory

wheese

ModerateTalking

Few words

+

+

Severe

20-30

100-120

10-25 mmHg

%60-80

> 60 mmHg

< 45 mmHg

%91-95

generalised

(Full eksp)

SevereRest (Ortopnea)

Word

+

+

Severe

> 30

> 120

> 25 mmHg

< %60

< 60 mmHg

> 45 mmHg

< %90

Expiratory and

inspiratory

Treatment in mild attack

inhaled short acting beta2 agonist 4-8 puff every 20 min for the first hour/ nebulization (2,5 mg) 1-2 times

O2 optional If incomplete improvement after the first hour repeat

the protocole Partial improvement: moderate attack treatment

Moderate attack treatment

Nasal O2 1-2 lt/min İnhaled short acting beta2

agonist+anticholinergic

4-8 puf/20 min/hour then 2-4 puff/hour

Oral or IV prednisolon 0.5-1 mg/kg

(divided to 2-4 doses)

Continue to treatment 1-3 hours

Severe attack treatment

4-6 lt/min nasal O2 5 mg salbutamol nebulisation/20 min or continious

nebulisation 0.15-0.30 mg/kg (Anticholinergic) 0.5 mg ipratropium bromide

nebulisation IV prednisolon 1-1.5 mg/kgNo response after the first 1-2 hours: Nasal O2 continued IV prednisolon repeated every 4 hours (Total 120-180

mg/day) Salbutamol+ anticholinergic nebulisation repeated every

4 hours IV Aminophyline 6mg/kg in 10-15 min than 0.6-0.9

mg/kg/hr infusion İv magnesium 2 gr/50 ml SF (30 min infüsion) sc or ıv adrenaline if necessary

8-10 hours follow up

Unresponsive to treatment, detoriation; Intensive care

Incomplete remission: Hospitalization(If PEF < %70)

Fine response: Discharge(If PEF > %70)

ventolin

bricanyl

atrovent

combivent

Teobag 200mg/100 ml

Prednol amp

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