Transcript Bronchial Asthma

Bronchial Asthma
DR. KAPIL D . SALGIA
MD(CHEST&TB)
Definition
• Asthma is a chronic inflammatory disorder of the
airways in which many cells and cellular elements
play a role.
• The chronic inflammation causes an associated
increase in airway hyperresponsiveness that leads
to recurrent episodes of wheezing ,
breathlessness,chest tightness and coughing,
particularly at night or in the early morning.
• These episodes are usually associated with
widespread but variable airflow obstruction that is
often reversible either spontaneously or with
treatment.
Epidemiology:
• Prevalance rate : 0 – 30% in children
worldwide.
• In adults prevalance rate may vary because
of confounding factors.
• Hospital admissions and morbidity lower
with newer medications.
Pathophysiology
The Underlying Mechanism
Risk Factors (for development of asthma)
INFLAMMATION
Airway
Hyperresponsiveness
Airflow Limitation
Risk Factors
(for exacerbations)
Symptoms(shortness of breath,
cough, wheeze)
Risk Factors
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HOST
A) Genetic predisposition.
B) Atopy.
C) Airway hyperresponsiveness.
D) Gender.
E) Race/ Ethnicity.
Risk Factors:
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ENVIRONMENTAL:
A) Indoor allergens.
B) Outdoor allergens.
C) Occupational sensitisers.
D) Air pollution.
E) Respiratory infections.
F) Parasitic infections.
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G) Socioeconomic status.
H) Family size.
I) Diet and drugs.
J) Obesity.
Trigger Factors:
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URTI.
Allergic rhinitis.
GERD.
Seasonal variation
Dust, smoke, smell.
Pollution.
Occupation.
Clinical History
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Breathlessness - Episodic/paroxysmal
Wheezing, Chest tightness.
Cough – Episodic - lasting 10 days or more
Cold.
Seasonal variability,precipitating factors.
Family history.
Response to anti-asthma treatment.
Physical Examination:
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Tachypnea.
Tachycardia.
Accessory muscles active.
Bilateral expiratory polyphonic rhonchi.
Cyanosis.
Pulsus paradoxus.
Hyperinflation.
Remember - Absence of symptoms at the time
of examination does not exclude the diagnosis
of asthma
Diagnosis:
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History and examination.
Peak expiratory flow rate (PEFR)
Spirometry.
Bronchoprovocation test (BPT).
Exhaled NO,CO.
Skin test.
PEFR
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Bedside monitoring.
Cheap.
Convenient.
Non-invasive.
Reproducible.
Occupational asthma.
Reliable.
PEFR
Variability:
( Min%Max)
• Min prebronchodilator
morning PEFR
expressed as a
percentage of recent
best.
• Diurnal variation >
20% is diagnostic.
Reversibility:
• Criteria of airway
hyperresponsiveness.
• Post bronchodilator
(PEF)-Pre b’dilator
expressed as
percentage of Pre
bronchodilator (PEF)
• Reversibility > 15 %
favours a diagnosis
Spirometry
• FEV 1/ FVC < 80%
in adults.
• FEV1 < 80%.
• Reversibility > 12%.
• IF normal
spirometry, plan
BPT.
Other Investigations:
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Hemogram.
X-ray Chest.
ENT evaluation.
Total serum IgE.(ABPA)
HRCT.
Classification of Asthma.
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INTERMITTENT
Symptoms< 1/week.
Brief exacebrations.
Nocturnal symptoms
not more than 2/mth.
PEF,FEV1>80%.
Variablity <20%.
MILD PERSISTENT
• Symptoms >1/wk but
not daily.
• Exacebrations + +
• Nocturnal symptoms
more than 2/ mth.
• FEV1,PEF > 80%.
• Variability 20-30%.
MODERATE PERSISTENT:
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Symptoms daily.
Exacebrations affect activity and sleep.
Nocturnal symptoms > once a week.
Daily use of β2 agonist.
FEV1,PEF 60-80%.
Variability > 30%.
SEVERE PERSISTENT:
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Symptoms daily.
Frequent exacebrations.
Frequent nocturnal symptoms.
Limitation of physical activities.
FEV1,PEF < 60%.
Variability >30%.
Goals to Be Achieved in
Asthma Control
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Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Minimal use of reliever medication
No emergency visits to doctors or hospitals
Maintain normal activity levels, including
exercise
• Maintain pulmonary function as close to normal as
possible
• Minimal (or no) adverse effects from medicine
Patient Education in the
Clinic
• Explain nature of the disease (i.e.
inflammation)
• Explain action of prescribed drugs
• Stress need for regular, long-term therapy
• Allay fears and concerns
• Peak flow reading
• Treatment diary / booklet
Tool Kit for Achieving
Management Goals
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Relievers
Preventers
Peak Flow meter
Patient education
What Are Relievers?
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Rescue medications
Quick relief of symptoms
Used during acute attacks
Action lasts 4-6 hrs
RELIEVERS
• Short acting 2 agonists
Salbutamol
Levosalbutamol
• Anti-cholinergics
Ipratropium bromide
Tiotropium
• Xanthines
Theophylline
• Adrenaline injections
Beta 2 Agonists
• Short and long acting
• Bronchodilators
• S/E : tremors,palpitations,hypokalemia
headaches,tachycardia,BP rise.
• Eg: salbutamol,salmeterol,formeterol,
• bambuterol,terbutaline.
What are Preventers?
– Prevent future attacks
– Long term control of asthma
– Prevent airway remodelling
Steroids (inhaled&oral)
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Anti-inflammatory
Controller medication
No systemic side effects at normal doses
Eg:Budesonide (400-800 mcgs)
: Beclamethasone ( 500-1000mcgs)
: Fluticasone ( 250- 500 mcgs)
oral:prednisolone,methylpred.
Ideal combination
• Formoterol ( fast relief and sustained relief )
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• Budesonide ( twice or even once daily use )
Dose: 1- 4 puffs ( OD/BD )
Another combination Salmeterol +
Fluticasone
Methylxanthines
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PDE inhibitors.
Bronchodilator.
Immunomodulator.
S/E: tremors, palpitations,ectopics,
Arrythmias,gastritis,convulsions,drug
interactions
• Eg:aminophylline,theophylline
Others
A)Leukotriene receptor antagonists:LTB4
Eg: monteleukast,romilast.
B)Cromones : mast cell stabiliser
Eg: sodium cromoglycate,nedocromil.
C)Antihistaminics
D)Oral antiallergic:
Eg: tranilast,repirinast
Others Continued
E) Steroid sparing agents : Immunomodulators&
macrolides.
Eg:cyclosporins,methotrexate,troleandomycin.
F) Specific Immunotherapy (SIT)
Severity
Controller
Others
Intermittent
None
Salbutamol SOS
Mild Persistent
Inhaled steroids
(<500microgms BDP)
Theophylline,or
Cromone,or Monteleukast
Moderate Persistent
ICS (200-1000microgms) + ICS+Theophy or
LABA
ICS+LABA (oral or ICS
>1000mic or ICS +LTB4
Severe Persistent
ICS(>1000mic)+ LABA +
1 or more LTB4,
Theophylline, oral LABA ,
Oral steroids
Tried but not tested
• Alternative therapies – Yogas etc.
All Asthma Drugs Should Ideally Be Taken
Through The Inhaled Route
Why inhalation therapy?
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Oral
Slow onset of action
Large dosage used
Greater side effects
Not useful in acute symptoms
Inhaled route
Rapid onset of action
Less amount of drug used
Better tolerated
Treatment of choice in acute symptoms
MDI
DPI
SPACER
Advantages of Spacer
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No co-ordination required
No cold - freon effect
Reduced oropharyngeal deposition
Increased drug deposition in the
lungs
Rotahaler - The dry powder
advantage
• Overcomes hand-lung coordination
problems that are encountered with
MDIs.
• Can be easily used by children, elderly
and arthritic patients.
• Can take multiple inhalations if the
entire drug has not been inhaled in one
inhalation.
Age-wise selection of
inhaler devices
• < 3 years – MDI + Spacer + Mask or
nebulisers
• 3 – 5 years – MDI + Spacer + Mask or
Rotahaler
• 5 – 8 years – Rotahaler or MDI +
Spacer
• > 8 years – Rotahaler or MDI + Spacer
Difficult Asthma
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Wrong Diagnosis
Compliance
Technique
Vocal cord dysfunction
ENT disorder
Psychological
Churg strauss/ PAN
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Nocturnal asthma
Premenstrual
Steroid resistant asthma
Steroid dependant asthma
Brittle asthma
Obstructed asthma
OSA
Nocturnal Asthma
Optimal lung functions at
4pm which drop to a nadir
at 4am.
Factors:
Cortisol
Histamine
Epinephrine
cAMP
Management
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OSA- CPAP
GERD – Head elevation,antacids,domstal
Deliberate nocturnal awakening for BD
URTI – anti-histaminics,decongestants
Warm humid air
Muscle training
Pharmacological management
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LABA + ICS
Long acting B2 agonist
Theophylline
Steroids
Cromones
Anticholinergic agents
Steroid Resistant Asthma
• Failure to demonstrate a rise in FEV1>15%
after 20mg steroids for 1 week f/b 40mg
steroids for 1 wk.
• Type1: GR binding affinity reduced(R)
• Type2: GR reduced normal affinity (I)
• Type 3: abnormal binding of GR
Treatment
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Check technique/ delivery system
Dose adjustment
Antacids- if poor absorption
Alternate ROA
Drug interactions: Rcin,anticonvulsants
Different formulations
Alternative Mx
• GR binding affinity reduced: Steroids >40
mg/day-----Serious S/E.
• Immunosuppresants:Mtx,gold,cyclosporine
• LTR antagonist
• PDE inhibitor
• Phospholipase inhibitor
Occupational asthma
Occupational asthma
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10% of adult onset asthma may be occupational
The commonest industrial lung disease in the
developed world
Adults with airflow obstruction should be asked:
“Are you better on days away from work?”
“Are you better on holiday?”
Those with positive answers should be
investigated for occupational asthma
In patients with adult onset asthma, clinicians
should be suspicious that there may be an
occupational cause
Confirming and managing
occupational asthma
• In suspected work-related asthma, the diagnosis of asthma
should first be confirmed using standard objective criteria
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Obtain objective confirmation of occupational asthma before
a worker is permanently relocated or dismissed
• Specific bronchial challenges should only be conducted in
specialised units
• Relocation away from exposure should occur within 12 months
of the first work-related symptoms of asthma
• Delay assessment of long term impairment for at least 2 years
following relocation away from exposure
essages
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Asthma can be effectively controlled, although it can
 Effective asthma management programs include edu
 A stepwise approach to pharmacologic therapy is rec
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