ASTHMA. Asthma definition: “Asthma is a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyper responsiveness.

ASTHMA

Asthma definition:

“Asthma is a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyper responsiveness. It presents with recurrent episodes of wheeze, cough, shortness of breath, and chest tightness.”

Clinical features that increase the probability of asthma

More than one of the following symptoms:

• Wheeze, cough, Difficulty in Breathing , chest tightness, particularly if

symptoms:– are frequent and recurrent– are worse at night and in the early morning– occur in response to, or are worse after, exercise or other triggers,

such as exposure to pets, cold, damp air, or with emotions/laughter

• Personal history of atopic disorder

• Family history of atopic disorder and/or asthma

• Widespread wheeze heard on auscultation

• History of improvement in symptoms or lung function in response to

adequate therapy

Clinical features that lower the probability of asthma

• Symptoms with colds only, with no interval symptoms

• Isolated cough in the absence of wheeze or difficulty breathing

• History of moist cough

• Prominent dizziness, light-headedness, peripheral tingling

• Repeatedly normal physical examination of chest when symptomatic

• Normal peak expiratory flow (PEF) or spirometry when symptomatic

• No response to a trial of asthma therapy

• Clinical features pointing to alternative diagnosis

Causes of Asthma

• The development of asthma appears to involve the interplay between host factors

(particularly genetics) and environmental exposures that occur at a crucial time in

the development of the immune system.

• Innate immunity: Imbalance between Th1-type and Th2- type cytokine responses in

early life. The immune response will down regulate the Th1 immune response that

fights infection and instead will be dominated by Th2 cells, leading to the expression

of allergic diseases and asthma. This is known as the “hygiene hypothesis,”

• which postulates that certain infections early in life, exposure to other children ,

less frequent use of antibiotics, and “country living” is associated with a Th1

response and lower incidence of asthma, whereas the absence of these factors is

associated with a persistent Th2 response and higher rates of asthma.

• Genetics: Asthma has an inheritable component, but the genetics involved remain

complex.

• Environmental factors: Two major factors are the most important in the

development, persistence, and possibly the severity of asthma:

airborne allergens (particularly sensitization and exposure to house-dust mite and

Alternaria)

viral respiratory infections (including respiratory syncytial virus [RSV] and

rhinovirus).

• Other environmental factors are under study:

tobacco smoke (exposure in utero is associated with an increased risk of wheezing,

but it is not certain this is linked to subsequent development of asthma),

air pollution (ozone and particular matter) and

diet (obesity or low intake of antioxidants and omega-3 fatty acids).

Mechanisms: Asthma Inflammation

Asthma Inflammation: Cells and Mediators

Early Childhood Risk Factors

Parental Asthma

Allergy

– Atopic dermatitis

– Allergic rhinitis

– Food allergy

– Inhalant allergen sensitization

– Food allergen sensitization

Precipitating and/or aggravating factors

• Viral respiratory infections

• Environmental allergens, indoor (e.g., mold, house-dust mite, cockroach,

animal dander or secretory products) and outdoor (e.g., pollen)

• Characteristics of home including age, location, cooling and heating

system, wood-burning stove, humidifier, carpeting over concrete,

presence of molds or mildew, presense of pets with fur or hair,

characteristics of rooms where patient spends time (e.g., bedroom and

living room with attention to bedding, floor covering, stuffed furniture)

• Smoking (patient and others in home or daycare)

• Exercise

• Occupational chemicals or allergens

• Environmental change (e.g., moving to new home; going on vacation;

and/or alterations in workplace, work processes, or materials used)

• Irritants (e.g., tobacco smoke, strong odors, air pollutants, occupational

chemicals, dusts and particulates, vapors, gases, and aerosols)

• Emotions (e.g., fear, anger, frustration, hard crying or laughing)

• Stress (e.g., fear, anger, frustration)

• Drugs (e.g., aspirin; and other nonsteroidal anti-inflammatory drugs, beta-

blockers including eye drops, others)

• Food, food additives, and preservatives (e.g., sulfites)

• Changes in weather, exposure to cold air Endocrine factors (e.g., menses,

pregnancy, thyroid disease)

• Comorbid conditions (e.g. sinusitis, rhinitis,GERD )

Classifying Severity and Initiating Treatment

CLINICAL FEATURES

Symptoms:Intermittent dry coughExpiratory wheezingShortness of breathChest tightnessChest painFatigueDifficulty keeping up with peers in physical activities

Signs:Expiratory wheezingProlonged expiratory phaseDecreased breath soundsCrackles/ ralesAccessory muscle useNasal flaringAbsence of wheezing in severe casesPulses paradoxus

Spirometry:Feasible in children >6 years of ageMonitoring Asthma and efficacy of treatmentMeasures FVC, FEV 1 and FEV1/FVC RatioNormal values for children available on the basis of height, gender and ethnicity.

Airflow Limitation: Low FEV1 FEV1/ FVC ratio < 0.80

Bronchodilator response to β-agonist: Improvement in FEV1 ≥ 12%

Exercise challenge: Worsening of FEV1 ≥ 15%

Peak expiratory flow rate: It is highly suggestive of asthma when:>15% increase in PEFR after inhaled short acting β2 agonist>15% decrease in PEFR after exerciseDiurnal variation > 10% in children not on bronchodilator

X-ray : Often normal, sometimes Hyperinflation

DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA

Age Common Uncommon Rare

Less than6 months

BronchiolitisGastro-esophagealreflux

Aspiration pneumoniaBronchopulmonary dysplasiaCongestive heart failureCystic fibrosis

AsthmaForeign body aspiration

6 months -2 years

BronchiolitisForeign bodyaspiration

Aspiration pneumoniaAsthmaBronchopulmonary dysplasiaCystic fibrosisGastro-esophageal reflux

Congestive heart failure

2 - 5 years AsthmaForeign bodyaspiration

Cystic fibrosisGastro-esophageal refluxViral pneumonia

Aspiration pneumoniaBronchiolitisCongestive heart failureGastro-esophageal reflux

APPROACH

Detailed historySymptoms Cough, Wheezing, Shortness of breath, Chest tightness, Sputum productionPattern of symptomsPerennial, seasonal, or both Continual, episodic, or both Onset, duration, frequency (number of days or nights, per week or month) Diurnal variations, especially nocturnal and on awakening in early morningFamily history History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps in close relatives

Social history Daycare, workplace, and school characteristics that may interfere with adherence Social factors that interfere with adherence, such as substance abuse Social support/social networks Level of education completed Employment

History of exacerbationsUsual prodromal signs and symptoms Rapidity of onset Duration Frequency Severity (need for urgent care, hospitalization, intensive care unit (ICU) admission.) Life-threatening exacerbations (e.g., intubation, intensive care unit admission) Number and severity of exacerbations in the past year. Usual patterns and management (what works?)

Impact of asthma on patient and family Episodes of unscheduled care (emergency department (ED), urgent care, hospitalization) Number of days missed from school/work Limitation of activity, especially sports and strenuous work History of nocturnal awakening Effect on growth, development, behavior, school or work performance, and lifestyle Impact on family routines, activities, or dynamics Economic impact

Assessment of patient’s and family’s perceptions of disease

• Patient’s, parent’s, and spouse’s or partner’s knowledge of asthma and

belief in the chronicity of asthma and in the efficacy of treatment

• Patient’s perception and beliefs regarding use and longterm effects of

medications

• Ability of patient and parents, spouse, or partner to cope with disease

• Level of family support and patient’s and parents’, spouse’s, or partner’s

capacity to recognize severity of an exacerbation

• Economic resources

• Sociocultural beliefs

Asthma Management and PreventionProgram: Five Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

1. Develop Patient/Doctor Partnership

Guidelines on asthma management should be available for local use by local asthma planning teams

Clear communication between health care professionals and asthma patients is key

Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family

2. Identify and Reduce Exposure to Risk Factors

Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.

Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs. Reduce exposure to indoor allergensAvoid tobacco smokeAvoid vehicle emissionIdentify irritants in the workplaceExplore role of infections on asthma development, especially in children and young infants

Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised

3. Assess, Treat and Monitor Asthma

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional.

The focus on asthma control is important because:Attainment of control correlates with a better quality of life, and

reduction in health care useDetermine the initial level of control to implement treatment (assess

patient impairment)Maintain control once treatment has been implemented (assess

patient risk)

Characteristic Controlled(All of the following)

Partly controlled(Any present in any week)

Uncontrolled

Daytime symptomsTwice or less

per weekMore than

twice per week

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

Limitations of activities None Any

Nocturnal symptoms / awakening None Any

Need for rescue / “reliever” treatment

Twice or less per week

More than twice per week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Levels of Asthma Control (Assess patient impairment)

Assess Patient Risk

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent exacerbations in past year

Ever admission to critical care for asthma

Low FEV1, exposure to cigarette smoke, high dose medications

Depending on level of asthma control, the patient is assigned to one of five treatment steps

Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:

- Assessing Asthma Control

- Treating to Achieve Control

- Monitoring to Maintain Control

A stepwise approach to pharmacological therapy is recommended

The aim is to accomplish the goals of therapy with the least possible medication

Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

The choice of treatment should be guided by:

Level of asthma control

Current treatment

Pharmacological properties and availability of the various forms of asthma treatment

Economic considerations

Cultural preferences and differing health care systems

Medications in Asthma

Controller Medications • Inhaled glucocorticosteroids• Leukotriene modifiers• Long-acting inhaled β2-agonists in

combination with inhaled glucocorticosteroids

• Systemic glucocorticosteroids • Theophylline• Cromones• Anti-IgE

Reliever Medications

• Rapid-acting inhaled β2-agonists

• Systemic glucocorticosteroids

• Anticholinergics

• Theophylline

• Short-acting oral β2-agonists

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose(g) > 5 y Age < 5 y

Medium Daily Dose (g) > 5 y Age < 5 y

High Daily Dose (g) > 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500 500-1000 >1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapy using allergen extracts has been

obtained in the treatment of allergic rhinitis

The role of specific immunotherapy in asthma is limited

Specific immunotherapy should be considered only after strict

environmental avoidance and pharmacologic intervention, including

inhaled glucocorticosteroids, have failed to control asthma

Perform only by trained physician

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E

Treating to Maintain Asthma Control

When control as been achieved, ongoing monitoring is essential to:

- maintain control

- establish lowest step/dose treatment

Asthma control should be monitored by the health care professional and by the patient

Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids:

50% dose reduction at 3 month intervals.

When controlled on low-dose inhaled glucocorticosteroids: switch to once-

daily dosing

When controlled on combination inhaled glucocorticosteroids and long-

acting inhaled β2-agonist: reduce dose of inhaled glucocorticosteroid by 50%

while continuing the long-acting β2-agonist

If control is maintained: reduce to low-dose inhaled glucocorticosteroids

and stop long-acting β2-agonist

Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide

temporary relief.

Need for repeated dosing over more than one/two days signals need for possible

increase in controller therapy

Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and

an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a

controller and reliever is effecting in maintaining a high level of asthma control and

reduces exacerbations

Doubling the dose of inhaled glucocortico-steroids is not effective, and is not

recommended

Component 4: Manage Asthma Exacerbations

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervisionTreatment of exacerbations depends on:

The patientExperience of the health care professionalTherapies that are the most effective for the particular patientAvailability of medicationsEmergency facilities

Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled β2-agonist

Early introduction of systemic glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serial measures of lung function

5.Special considerations

Special considerations are required to manage asthma in relation to:

Pregnancy

Surgery

Rhinitis, sinusitis, and nasal polyps

Occupational asthma

Respiratory infections

Gastroesophageal reflux

Aspirin-induced asthma

Anaphylaxis and Asthma

STATUS ASTHAMATICUS

• Status asthmaticus is the condition of a patient in progressive

respiratory failure due to asthma, in whom conventional

forms of therapy have failed

Status Asthamaticus Assessment

Findings consistent with impending respiratory failure:Altered level of consciousnessInability to speakAbsent breath soundsCentral cyanosisDiaphoresisInability to lie downMarked pulsus paradoxus

Clinical Asthma Score

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