Asthma pdf - D. Majeed

بسم هللا الرحمن الرحيم

Respiratory Medicine

05 /02/2020

Dr.Majeed Mohan Alhamami

Objectives

• Defintion
• Epidemiology
• Clinical presentation in emergency and

outpatient.

• Diagnosis
• Treatment of the emergency and chronic

condition.

• Complication
• prognosis

Asthma

• Asthma is a common chronic inflammatory

condition of the lung airways whose cause is
still incompletely understood.

Asthma has three characteristics:

• Airflow limitation which is usually reversible

spontaneously or with treatment .

• Airway hyperresponsiveness to a wide range

of stimuli .

• Inflammation of the bronchi with

eosinophils, T lymphocytes and mast cells
with associated plasma exudation, oedema,
marked smooth muscle hypertrophy, mucus
plugging and epithelial damage.

Typical symptoms include
• wheeze,
• cough,
• chest tightness
• dyspnoea

Epidemiology

• The prevalence of asthma increased steadily.
• that asthma affects 300 million people world-

wide

• an additional 100 million persons will be

diagnosed by 2025.

World map showing the prevalence of clinical asthma

(proportion of population (%)). Data drawn from the

European Community Respiratory Health Study (ECRHS) and

the International Study of Asthma and Allergies in Childhood

(ISAAC).

Classification

• Asthma can be divided into:
• extrinsic - implying a definite external cause

• intrinsic or cryptogenic - when no causative

agent can be identified.

Extrinsic asthma

• Most frequently in atopic individuals.
• Atopy or positive skin-prick tests to inhalant

allergens are shown in 90% of children and
50% of adults with persistent asthma.

• Childhood asthma is often accompanied by

eczema .

Intrinsic asthma

• often starts in middle age ('late onset').
• Non-atopic
• from extrinsic causes such as sensitization to

occupational agents

• aspirin intolerance
• β-adrenoceptor-blocking agents.

• Extrinsic causes must be considered in all

cases of asthma and, where possible,
avoided.

• Aspirin-sensitive asthma .
• In exercise-induced asthma,

Factors implicated in the development of, or

protection from, asthma.

Asthma Traditional Therapy

Approach

Tattersfield AE, et al. Am J Respir Care Med 1999; 160:594-9

2. FitzGerald JM, et al. Can Respir J 2003; 10(8):427

Bateman et al .J Allergy Clin Immunol 2010; 125: 600-8

•

Reversibility test. Forced expiratory before and 20

minutes after inhalation of a

-adrenoceptor

agonist. Note the

increase in FEV

from 1.0

2.5 L

Airway hyper-reactivity in asthma.

Changes in peak flow following allergen challenge. A similar biphasic

response is observed following a variety of different challenges.

Occasionally an individual will develop an isolated late response with

no early reaction

• Airway hyper-reactivity in asthma. This is

demonstrated by bronchial challenge tests by the
administration of sequentially increasing
concentrations of either histamine, methacholine or
mannitol. The reactivity of the airways is expressed
as the concentration or dose of either chemical
required to produce a certain decrease (usually 20%)
in the FEV

(PC

or PD

respectively).

Diurnal pattern

Asthma characteristically displays a diurnal

pattern,

with symptoms and lung function being worse in

the

early morning. Particularly when poorly

controlled,

symptoms such

Serial recordings of peak expiratory flow (PEF) in a patient with

asthma. Note the sharp overnight fall (morning dip) and

subsequent rise during the day. In this example corticosteroids

have been commenced, followed by a subsequent improvement

in PEF rate and loss of morning dipping.

Exercise-induced asthma. Serial recordings of FEV

in a patient with

bronchial asthma before and after 6 minutes of strenuous exercise.

Note initial slight rise on completion of exercise, followed by sudden

fall and gradual recovery. Adequate warm-up exercise or pre-

treatment with a β

-adrenoceptor agonist, nedocromil sodium or a

leukotriene antagonist (e.g. montelukast sodium) can protect against

time in minute

)

exercise-induced symptoms.

Making a diagnosis of asthma

• Compatible clinical history plus either/or: FEV

≥ 15%* (and 200 mL) increase following
administration of a bronchodilator/trial of
corticosteroids

• > 20% diurnal variation on ≥ 3 days in a week

for 2 weeks on PEF diary

• FEV

≥ 15% decrease after 6 mins of exercise

Signs

• Depend on severity

• Conscious level     normal-………. coma
• Respiratory rate   normal-tachypnoea-…….apnoea
• Blood pressure   hypertension(vasculitis) paradox
• Pulse rate
• Position
• Chest examination   normal in mild type

hyperinflation in chronic one

Prolonged expiration exp,inspiratory

rhonchi

Level of asthma control

GINA 2018

– main treatment figure

GINA 2018, Box 3-5 (2/8) (upper part)

Previously, no controller was

recommended for

Step 1, i.e. SABA-only

treatment was ‘preferred’

Step 1 treatment is for

patients with symptoms

<twice/month and no risk

factors for exacerbations

Off-label; data only with budesonide-formoterol (bud-form)

†

Off-label; separate or combination ICS and SABA inhalers

PREFERRED

CONTROLLER

to prevent exacerbations

and control symptoms

Other

controller options

Other

reliever option

PREFERRED

RELIEVER

STEP 2

Daily low dose inhaled corticosteroid (ICS),

or as-needed low dose ICS-formoterol *

STEP 3

Low dose

ICS-LABA

STEP 4

Medium dose

ICS-LABA

Leukotriene receptor antagonist (LTRA), or

low dose ICS taken whenever SABA taken

†

As-needed low dose ICS-formoterol *

As-needed short-acting

-agonist (SABA)

Medium dose

ICS, or low dose

ICS+LTRA #

High dose

ICS, add-on

tiotropium, or

add-on LTRA #

Add low dose

OCS, but

consider

side-effects

As-needed low dose ICS-formoterol

‡

Box 3-5A

Adults & adolescents 12+ years

Personalized asthma management:

Assess, Adjust, Review response

Asthma medication options:

Adjust treatment up and down for

individual patient needs

STEP 5

High dose

ICS-LABA

Refer for

phenotypic

assessment

± add-on

therapy,

e.g.tiotropium,

anti-IgE,

anti-IL5/5R,

anti-IL4R

Symptoms

Exacerbations

Side-effects

Lung function

Patient satisfaction

Confirmation of diagnosis if necessary

Symptom control & modifiable

risk factors (including lung function)

Comorbidities

Inhaler technique & adherence

Patient goals

Treatment of modifiable risk

factors & comorbidities

Non-pharmacological strategies

Education & skills training

Asthma medications

STEP 1

As-needed

low dose

ICS-formoterol

Low dose ICS

taken whenever
SABA is taken

†

‡ Low-dose ICS-form is the reliever for patients prescribed

bud-form or BDP-form maintenance and reliever therapy

Consider adding HDM SLIT for sensitized patients with

allergic rhinitis and FEV >70% predicted

Management approach based on asthma control. For

children older than 5 years, adolescents and adults. (ICS =

inhaled corticosteroid) *Receptor antagonist or synthesis

inhibitors

How to use a metered-dose inhaler.

Step 3: assess inhaler

technique

Step 4: assess patient adherence to treatment

Step 5: exclude alternative or

overlapping diagnosis as primary

conditions

Step 7-

Environmental Factors:

Action - Advice on allergens avoidance

Animals outside the home (cats, dogs, hamsters)
Dust Mites: Allergy Waterproof Cases
Damp cloth and vacuum
Home Humidity <50%
No carpets in the bedroom
Washing with hot water weekly
Pollens: Close windows in time of pollination
Snuff: Avoid smoking and passive exposure
Fungi: Remove mildew stains on the walls
Avoid wood stoves, smoke, air fresheners, etc..

Classification of severity of asthma

exacerbations.

Symptoms

Speech

•

Mild Breathlessness With activity Sentences

• Moderate With talking Phrases
• Severe At rest Words
•

Impending Respiratory Failure At rest Mute

•

Mild Moderate Severe Impending Respiratory Failure

Signs

Body position

Able to recline Prefers sitting Unable to recline Unable to recline

Respiratory rate

Increased Increased

Often > 30/min > 30/min

Use of accessory respiratory muscles

Usually not Commonly Usually Paradoxical thoracoabdominal

movement

Pulsus paradoxus (mm Hg) Mental status

Mild < 10 May beagitated

Moderate 10–25 Usually agitated

Sever often > 25 Usually agitate
Impending Often absent Confused or drowsy

Mild Moderate Severe Impending Respiratory Failure

•

Breath sounds Heart rate

(beats/min)

Moderate wheezing at mid- to end-expiration < 100

Loud wheezes throughout expiration               100-120
Loud inspiratory and expiratory wheezes              > 120
Little air movement without wheezes     Relativebradycardia

Mild Moderate Severe Impending Respiratory Failure

• Functional assessment

•

PEF (% predicted or personal best)

> 80 50–80 < 50 or response to therapy lasts < 2 hours < 50

• SaO

(%, room air)

> 95 91–95 < 91 < 91

•

Pa O

(mm Hg, room air)

Normal > 60 < 60 < 60

• Pa CO

(mm Hg)

< 42 < 42 42 42

Immediate treatment of patients with acute severe asthma.

Indications for assisted ventilation in

acute severe asthma

• Coma
• Respiratory arrest
• Deterioration of arterial blood gas tensions

despite optimal therapy

– PaO

< 8 kPa (60 mmHg) and falling

– PaCO

> 6 kPa (45 mmHg) and rising

– pH low and falling (H

high and rising)

• Exhaustion, confusion, drowsiness

Symbicort® efficacy enhanced by Turbuhaler

Device

36%

Diskus 12%

•

Fine particles lead to higher lung

deposition that leads to higher

improvement in lung function

1-5

1. Borgstrom L et al., Int J Clin Pract, 2005, 59, 12, 1488-1495 2. Thorsson L et al., Int Journal of Pharmaceutics 168 (1998) 119-127

3. Usmani O, AM J Resp and Critical Care Medicine, vol 172 2005; 1497-1504 4. Selroos et al., Treat Resp Med 2006; 5 (suppl 48): 584S.

5. Selroos et al., Treat Resp Med 2006; 5 (5): 305-315

Device Comparison for lung deposition

Symbicort®… The only combination

treatment offering flexibility in

prescription

1 inhalation

every morning

Extra doses

when needed

1 inhalation

every evening

Symbicort Turbuhaler 160/4.5 mg/dose SX Leaflet text

Complication

• 1-Pnemothorax.
• 2-exacerbation.
• 3-bronchiectasis.
• 4-Respiratory failure.
• 5-Druge side effects.

Prognosis

Control can achieved as a chronic disease ,death

is uncommon.

Discussion and questions

Many thanks