Asthma

By: Samia Yaqoob Roll no. 15

Urooj Ilyas Roll no. 14

Topics to be covered….

Introduction (Etiology & Patho-physiology) Sign and Symptoms Acute & Severe Asthma Diagnosis Classification of Asthma & Its Treatment Management

A disease affecting 7 to 10%of population

More common in male children and female adults

Death rate is highest among blacks aged 15-24 years old

The most common reason for death are thought to be inadequate assessment for severity of airways obstruction or inadequate therapy with inhaled or oral steroids.

General consideration:

A chronic inflammatory disorder of the airways which occurs in susceptible individuals , inflammatory symptoms are usually associated with wide spread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible either spontaneously or with treatment.

Definition:

In asthma:

Airways become smaller or narrower, due to: Underlying

inflammation or swelling

Increased mucus production and

Contraction of muscles around the airways, or bronchospasm

The two main causes for asthma sypmtoms are:

1: Airway hypersensitivity 2: Bronchoconstriction Although there is no single cause of asthma, certain environmental and genetic factors are known to contribute to the development of the condition.

Etiology:

trigger examplesallergens Pollens, molds, house dust milds,

animal danderIndustrials chemicals Manufacture of isocyanate

containing paints, hair spray. Penicillins, cimitidine

drugs beta blockers, aspirin, ibuprofen and naproxen

foods  shrimp, dried fruit, processed potatoes, beer and wine, seafood

Environmental pollutants Traffic fumes, cigarette smokeMiscellenious Cold air

ExerciseEmotions and stressRespiratory infections, such as the common cold

Examples of asthma triggers:

Coughing, especially at night, during exercise or when laughing.

Shortness of breath. Chest tightness. Wheezing Any asthma symptom is serious and can

become deadly if left untreated.

Sign and symptoms:

Extrinsic asthma :o Develop in children with a history of atopyo Allergens( dust , mite etc) cause IgE

production

Intrinsic asthma:o Develop in adulthoodo Non allergic factors might be the cause such

as viral infections, irritants, stress, exercise , triggering mediators released from mast cell

Patho-physiology :

If an acute attack becomes persistent and difficult to treat, it is known as severe asthma

 It is a medical emergency that requires immediate recognition and treatment. 

Patients with status asthmaticus have severe dyspnea that has developed over hours to days.

Frequently, these individuals have a previous history of endotracheal intubation and mechanical ventilation, frequent emergency department visits, and previous use of systemic corticosteroids.

Acute severe asthma:

The exact mechanism underlying the development of an acute severe asthma attack remains elusive but there appear to be two phenotypes:

Gradual-onset - in about 80%, severe attacks develop over more than 48 hours. These are associated with eosinophilic infiltration and slow response to therapy.

Sudden-onset - often in association with significant allergen exposure. Patients tend to be older and to present between midnight and 8 am. This type of attack is associated with neutrophilic inflammation and a swifter response to therapy.

Acute severe asthma:

Shortness of breath may develop over hours or days but is usually progressive rather than sudden.

The patient will usually appear pink. Cyanosis is a serious sign.

Their respiratory rate is raised. Tachycardia is usual and may be increased by use of

beta2 agonists. chest appears hyper-inflated. In normal breathing, the ratio of the duration of inspiration to

expiration is about 1:2 but, as asthma becomes more severe, the expiratory phase becomes relatively more prolonged.

Wheeze is usually expiratory, but may also be inspiratory in more severe asthma.

Sign and sypmtoms:

Initial assessment Take a very quick history and brief

examination (conscious level, colour, pulse, blood pressure, respiratory rate, listening to chest, )

It might be : Mild or moderate Severe Life threatening

Management:

Mild / moderate: if a person presenting acute sever asthma but

can walk and speak whole sentences in one breath

Immediately: Give 4–12 puffs salbutamol (100 mcg per actuation) via pMDI plus spacer

continue bronchodilator Any of: persisting dyspnoea, inability to lie flat without dyspnoea,

For poor response:add ipratropium bromide 8 puffs (160 mcg) via pMDI (21 mcg/actuation)

Within first hour: start systemic corticosteroids. Oral prednisolone 37.5–50 mg then continue 5–10 days OR, if oral route not possible Hydrocortisone 100 mg IV every 6 hours

(1 hour after starting bronchodilator) Perform spirometry (if patient capable)

After 1 hr if dyspnoea resolved : Advise/arrange follow-up review

Mild / moderate:

Any of: unable to speak in sentences, visibly breathless, increased work of breathing, oxygen saturation 90–94%

Give 12 puffs salbutamol (100 mcg per actuation) via pMDI plus spacer OR Use intermittent nebulisation if patient cannot breathe through spacer. Give 5 mg nebule salbutamol. Drive nebuliser with air unless oxygen needed Start oxygen (if oxygen saturation less than 95%)

Sever asthma:

For poor response add ipratropium bromide 8 puffs (160 mcg)

via pMDI (21 mcg/actuation) Corticosteroids If sign remain unresolved continue

bronchodilator, and start IV sulbutamol in ICU

Further deterioration in condition required ventilation

Monitor arterial blood gas, oxygen saturation.

Sever asthma:

Person either collapsed , cynocytic, exhausted or oxygen saturation less than 90% , bradichardia shows that he is suffering from life threatening asthma.

Give sulbutamol (5mg) via continuous nubilization (5-10mg/hr)

Start suplimental oxygen In case of poor response within one hr give

ipratropium bromide(500mcg) After 1 hr start systemic corticosteroids( IV

hydrocortisone) Possible incubation and mechanical ventilation

Life threatening:

Continue treatment with inhaled SABAs Continue course of oral or systemic

corticosteroids for 7 days Patient education Before discharge schedule follow-up

appointment with primary care provider or asthma specialist in 1-4 weeks

Discharge home:

Topics to be covered….

Introduction (Etiology & Patho-physiology) Sign and Symptoms Acute & Severe Asthma Diagnosis Classification of Asthma & Its Treatment Management

Diagnosis

On follow-up visits: A medical historyi. Coughii. Breathing problem on doing physical activityiii. Chest tightnessiv. Wheezingv. Cold lasting timevi. Family history Lung function test (Spirometer and Peak Flow meter) Check for allergies by skin testing and blood IgE antibody

test.

Diagnosis:

Classification of Asthma & its

treatment

a/c to asthma control

Controlled Partly controlled

Uncontrolled

Classification

a/c to severity

Intermittent Mild persistent

Moderate persistent

Severe persistent

Considered intermittent if without treatment any of the following are true:

Symptoms (dyspnea, wheezing, chest tightness, coughing)◦ Occur on fewer than 2 days a week.◦ Do not interfere with normal activities.

Nighttime symptoms occur on fewer than 2 days a month.

Lung function tests: FEV or PEF > or equal to 80%

It is controlled type of asthma control.

Treatment: SABA prn. e.g. albuterol (Ventolin)

Intermittent:

Considered moderate persistent if without treatment any of the following are true: Symptoms:o occur on more than 2 days a week but do not occur every day.o Attacks interfere with daily activities.

Nighttime symptoms occur 3 to 4 times a month.

Lung function tests are normal, FEV or PEF > or equal to 80%.

It is partly controlled type of asthma control.

Treatment:o 0-4 yrs age: Low dose ICS (Beclomethasone :Qvar) OR Montelukast. (Myteka)o 5- 11 yrs age: Low dose ICS OR Cromolyn Na (Intal) , LTRA OR theophylline.o Above 12 yrs age: Low dose ICS OR Cromolyn Na , LTRA OR theophylline (Theo-Dur).

Mild persistent:

Considered moderate persistent if without treatment any of the following are true:

Symptoms o occur daily, inhaled short-acting asthma medication is used

every day.o Interfere with daily activities.

Nighttime symptoms occur more than 1 time a week, but do not happen every day.

Lung function tests are abnormal, FEV OR PEF 60- 80 %.

Moderate Persistent:

Treatment:

i. Treatment 1:o 0-4 yrs age: Medium dose ICSo 5-11 yrs age: Low dose ICS + LABA, LTRA or Theophylline or Medium dose ICSo Above 12 yrs: Low dose ICS+LABA or ICS alternative Low dose ICS + LTRA, Theophylline or Zileuton.

ii. Treatment 2:o 0-4 yrs age: Medium dose ICS +LABA Or Montelukast.o 5-11yrs age: Medium dose ICS + LABA alternative Medium dose ICS + LTRA or Theophyllineo Above 12 yrs age: Medium-dose ICS +LABA alternative Medium dose ICS + LTRA, Theophylline or Zileuton.

Contd:

Considered severe persistent if without treatment any of the following are true:

Symptoms:◦ Occur throughout each day.◦ Severely limit daily physical activities.

Nighttime symptoms occur often, sometimes every night.

Lung function tests are abnormal (60% or less of expected value), and PEF varies more than 30% from morning to afternoon.

Severe Persistent:

Treatment:i. Treatment 1:o 0-4 yrs age: High dose ICS + LABA or Montelukasto 5-11 yrs age: High dose ICS + LABA alternative High dose ICS + LTRA or Theophyllineo 12 or above age: High dose ICS + LABA alternative Omazulimab

ii. Treatment 2:o 0- 4 yrs age: High dose ICS + Oral corticosteroids +LABA or Montelukasto 5-11 yrs age: High dose ICS + LABA + Oral corticosteroids alternative High dose ICS + LTRA or Theophylline + Oral corticosteroidso 12 or above age: High dose ICS + LABA +Oral corticosteroids alternative consider omazulimab.

Contd:

Management

Management