Transcript bronchial asthma - Ain Shams University

BRONCHIAL
ASTHMA
Pulmonary Medicine Department
Ain Shams University
http://mic.shams.edu.eg/moodle5
At the end of this lecture the
student should be able to:
1.
2.
3.
4.
5.
6.
Know the definition of bronchial
asthma.
Know the epidemiology.
Discuss the risk factors.
Describe the clinical presentations.
Discuss the investigations.
Discuss the treatment (acute and
maintenance therapy)
What is asthma?
Asthma
is a chronic
inflammatory condition of the
airways
Three characteristics:
–Reversible airway obstruction
–Bronchial hyper-responsiveness
–Chronic inflammation
In
studying the ‘causes’ of
asthma, we must distinguish
between development and
exacerbation
Definition of Asthma
A chronic inflammatory disease of the airways
with the following clinical features:
• Episodic and/or chronic symptoms of airway
obstruction.
• Bronchial hyperresponsiveness to triggers.
• Evidence of at least partial reversibility of the airway
obstruction.
• Alternative diagnoses are excluded.
Definition



:
Asthma is a chronic inflammatory disorder of
the airways in which many cells and cellular
elements play a role.
The chronic inflammation is associated with
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
within the lung that is often reversible either
spontaneously or with treatment.
A Lot Going On
Beneath The Surface
Symptoms
Airflow
obstruction
Bronchial
hyperresponsiveness
Airway
inflammation
The Asthma Problem
• Currently affects 5-10% of US population
• >17 million Americans
• 150 million worldwide
• Incidence, severity increasing
• Mortality has plateaued
• still relatively rare
• Leading serious chronic illness among
children
• Since 1980, prevalence has doubled
• Leading cause of lost school days
• In the US, costs exceed $14 billion/yr
(NYT, 4/19/2003)
Asthma Interventions
medical
care
environment
Asthma
Development
Asthma
Exacerbation
genetics
environment
Asthma: Relevant exposures
 Biological
 Chemical
– Bacteria/viruses
– Tobacco smoke
– Cockroaches
– Building
materials
– Dust mites
– Carpet/furniture
– Molds
– Combustion
– Pets
products
– Pollen
– Household
– Rodents
chemicals
– Pesticides
 Social
– Stress
– Exposure to
violence
 Structural
– Water/moisture
– Heating,ventilation
and air conditioning
– Deteriorated
buildings
– Appliance disrepair
– Old carpet and
upholstery
Relevant biological exposures
• Allergens
• Pets (cats, dogs, rodents, etc.)
• Pests (cockroach, dust mite)
• Pollen
• Fungi (mold)
• Bacterial
• Endotoxins
• Viral
• Rhinovirus
• Respiratory Syncytial Virus
Allergens
• Dust mite
 Associated with development and exacerbation
of asthma (NAS, 2000)
• Cockroach
 Most common allergy among Inner City Asthma
Study subjects (Kattan et al. 1997)
 Early life exposure associated with development
of asthma (Litonjua et al. 2001)
• Mouse
 Dust allergen levels associated with
sensitization (Phipatanakul, 2000)
 Few studies on the association with asthma
development and symptoms
• Pets
 Effects of pet exposure depend on many factors:
sensitization, time of exposure, etc.
What are your objectives in caring
for bronchial asthma patient ?




Prevent serious
attacks
Require little or no
reliever medication
Prevent troublesome
symptoms night and
day
Have productive,
physical,
psychological, and
social active lives
n
f
i
l
t
r
– Immunohistopathologicatfeatures
i
 inflammatory cell infiltration
o
– Neutrophils (sudden, fatal asthma)
n
– Eosinophils
N
e
– Lymphocytes
u
t
r
o
p
h
i
l
s
(
s
u
 Airway
inflammation (AI) contributes
to hyperresponsiveness, airflow
limitation, symptoms & chronicity
What is the Pathophysiology?
Trigger Factor
 Mast cell
 Mediators :
histamine,prostaglandin,leukotrienes,as
well as cytokines.
 Inflammatory cells
 Sustained Inflammatory response
 Contraction of airway smooth muscles
(Bronchoconstriction)

Pathophysiology (Cont.)
Airway wall swelling (mucosal edema)
 Airway hyper responsiveness
 Chronic changes
 Hypertrophy of the smooth muscles,
thickening of the basement membrane
 Airway remodeling
 There is good evidence that asthma occurs
in families.

Changes in Airway Morphology in
Asthma
Mucous gland
hypertrophy
Edema
Epithelial
damage
Airway smooth
muscle
Inflammatory
cell infiltration
Mucus
Thickening
of basement
membrane
Vascular
dilation
Adapted from National Asthma Education and Prevention Program. Expert Panel Report.
Guidelines for the Diagnosis and Management of Asthma. August 1991.
What are the Triggering Factors?
Domestic dust
mites
 Air pollution
 Tobacco smoke
 Occupational
irritants
 Cockroach
 Animal with fur
 Pollen

Triggering Factors ( cont.)
Respiratory (viral)
infections
 Chemical irritants
 Strong emotional
expressions
 Drugs ( aspirin,
beta blockers)

HOW TO DIAGNOSE BRONCHIAL
ASTHMA ?
 Consultation
skill
 Relevant History
-Symptom
-history of allergic disease
-Family history
-Environmental history
-Exclusion of other medical
condition
Diagnosis of B.A ( cont.)
 Relevant
physical examination
 Investigation
Do you need to do investigation?
Why ?
 Follow up
 Medical record
 Role of Peak Flow Meter
CLASSIFY ASTHMA
SEVERITY
 Mild
intermittent Asthma (step1)
 Mild persistent Asthma (step2)
 Moderate persistent Asthma (step3)
 Severe persistent Asthma (step4)
How to manage and control
Bronchial Asthma
 Educate
patients to develop a
partnership in asthma care
 Assess and monitor asthma severity
 Avoid exposure to trigger factors
 Establish individual medication plans
for long term management in
children and adults
How to manage and control
Bronchial Asthma ( cont.)
 Establish
individual plans to manage
asthma attacks
 Provide regular follow up care.
Expert Panel Report 2:
Four Components of
Asthma Management

Measures of Assessment and Monitoring

Control of Factors Contributing to
Asthma Severity

Pharmacologic Therapy

Education for a Partnership in Asthma Care
Component 1:
Initial Assessment and Diagnosis of
Asthma

Determine that:
– Patient has history or presence of episodic symptoms of airflow
obstruction
– Airflow obstruction is at least partially reversible
– Alternative diagnoses are excluded

Methods for establishing diagnosis:
– Detailed medical history
– Physical exam
– Spirometry to demonstrate reversibility
Component 1:
Initial Assessment and
Diagnosis of Asthma (continued)
Does patient have history or presence of
episodic symptoms of airflow
obstruction?

Wheeze, shortness of breath, chest
tightness, or cough

Asthma symptoms vary throughout the day

Absence of symptoms at the time of the
examination does not exclude the diagnosis
of asthma
Initial Assessment and
Diagnosis of Asthma (continued)
Is airflow obstruction at least partially
reversible?

Use spirometry to establish airflow
obstruction:
– FEV1 < 80% predicted;
– FEV1/FVC <65% or below the lower limit of
normal

Use spirometry to establish reversibility:
– FEV1 increases >12% and at least 200 mL
after using a short-acting inhaled beta2-agonist
Benchmarks of Good Asthma
Control
 Infrequent
coughing or wheezing
 No shortness of breath or difficulty breathing
 No waking up at night due to asthma
 Normal physical activities
 No childcare or school absences due to asthma
 No missed time from work for parent or caregiver
AAAAI Guide
Classification Of Asthma Severity:
Clinical Features Before Treatment
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Mild
Intermittent
Days with
Symptoms
Nights with
Symptoms
PEV or
FEV1
Continual
Frequent
< 60
Daily
> 5/month
> 60% to
<80%
3-6/week
3-4/month
> 80%
< 2/week
< 2/month
> 80%



Red: Below 50% of
Personal Best
Yellow: 50% to 80% of
Personal Best
Green: 80% to 100% of
Personal Best
Pediatric Differential Diagnosis
 Chronic sinusitis
 Vocal cord
dysfunction (VCD)
 Croup
 Tracheomalacia
 Pertussis
 TE fistula
Foreign body
Bronchiolitis
Cystic fibrosis /
Ciliary dysfunction
GERD
Hyperventilation
syndrome
Component 2:
Control of Factors
Contributing to Asthma Severity
(continued)

Assess contribution of other factors:
–
–
–
–
–
Rhinitis/sinusitis
Gastroesophageal reflux
Drugs (NSAIDs, beta-blockers)
Viral respiratory infections
Sulfite sensitivity
The goal of asthma care is to achieve and
maintain control

To reach this goal, four interrelated components of
therapy are required:
– Component 1. Develop patient/doctor partnership
– Component 2. Identify and reduce exposure to risk
factors
– Component 3. Assess, treat, and monitor asthma
– Component 4. Manage asthma exacerbation
Develop patient/doctor
partnership
 Avoid
risk factors
 Take medications correctly
 Understand the difference between “controller”
and reliever” medications
 Monitor their status using symptoms and, if
relevant, PEF
 Recognize signs that asthma is worsening and
take action
 Seek medical help as appropriate.
Example of Contents of an Action Plan to
Maintain Asthma Control
– Your Regular Treatment
– When to Increase Treatment
– Assess your level of asthma Control
– How to Increase Treatment
– When to call the Doctor/Clinic
– Emergency/Severe Loss of Control
– Reliever medication
Stepwise approach ( children)
classificati
on
mild
Intermitte
nt
Mild
persistent
Moderate
persistent
Severe
persistent
Minor
symptoms
< 1/week
1-3 /week
4-5/week
Continuou
s
exacerbati
on/
nocturnal
< 1/month 1 /month
2-3/month > 4
/month
PEF
between
attacks
>80%
>80%
60-80%
< 60%
Step 1
Step 2
Step 3
Step 4
Stepwise approach ( adult)
classificati
on
mild
Intermitte
nt
Mild
persistent
Moderate
persistent
Severe
persistent
Minor
symptoms
< 2 /week
2-3 /week
4-5 /week
Continuou
s
exacerbati
on/
nocturnal
<2
/month
2-3
/month
4-5
/month
>5
/month
PEF
between
attacks
>80%
>80%
60-80%
< 60%
Step 1
Step 2
Step 3
Step 4
Paradigm Shift in Asthma
Asthma
Uncontrolled
Adjust
therapy
Difficult
to control
Controlled
Corticosteroids for Asthma:
Benefits and Risks
Dose, drug, &
route dependent
Reduces
inflammation
Decreases
morbidity / mortality
Most effective
long-term control
medication for
asthma*
Benefits
Generally known
and can be
monitored
Risks
– Long-acting ß2-agonists must only be used in
combination with an appropriate dose of inhaled
glucocorticosteroid.
– Long-acting oral ß2-agonists alone are no longer
presented as an option for add-on treatment at
any step of therapy, unless accompanied by
inhaled glucocorticosteroids.
Monitoring to Maintain Control
– Ongoing monitoring is essential to maintain
control and establish the lowest step and dose
of treatment to minimize cost and maximize
safety.
– Typically, patients should be seen one to three
months after the initial visit, and every three
months thereafter. After an exacerbation,
follow-up should be offered within two weeks to
one month.
Adjusting medication:
– If asthma is not controlled on the current treatment
regimen, step up treatment. Generally, improvement
should be seen within 1 month. But first review the
patient’s medication technique, compliance, and avoidance
of risk factors.
 If
asthma is partly controlled, consider stepping up
treatment, depending on whether more effective options
are available, safety and cost of possible treatment
options, and the patient’s satisfaction with the level of
control achieved.
– If control is maintained for at least 3 months, step down
with a gradual, stepwise reduction in treatment. The goal is
to decrease treatment to the least medication necessary to
maintain control.
Principles of Maintenance Therapy
 Start
high.
 Step down once control is
achieved.
 Maintain at lowest dose of
medication that controls asthma.
 Step up and down as indicated.
Step-down Therapy
Step down once control is achieved.
 After 2–3 mo.
 25% reduction over 2–3 mo.
Follow-up monitoring
 Every 1–6 mo.
 Assess symptoms.
 Review medication use.
 Objective monitoring (PEFR or
spirometery).
 Review medication.
Step-up Therapy
 Indications:
symptoms, need for
quick-relief medication, exercise
intolerance, decreased lung
function.
– May need short course of oral
steroids.
 Continue
to monitor.
– Follow and reassess every 1–6 mo.
– Step down when appropriate.
Manage Exacerbations
Definitions

Exacerbations of asthma (asthma attacks)
are episodes of a progressive increase in
shortness of breath, cough, wheezing, or
chest tightness, or a combination of these
symptoms.
Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly
and aggressively.
 Inhaled ß2-agonist inhalants for quick relief
 Access to quick relief medication
 Written action plan
– Indications
– Medications
– When to contact physician or emergency medical
services

Short course of oral corticosteroids
Acute Exacerbations
Office Management
Assess severity.







Symptoms, signs, lung function, pulse oximetry (if
available)

Oxygen recommended
Short acting ß2-agonist inhalant every 20–30 min
 Ipratropium—metered-dose inhaler, inhalation
solution
 Corticosteroid—orally, intravenous if vomiting
Intravenous favored if dehydrated
Follow-up—hours (phone) to 1–7 d
Medication
Adverse Effects
Short & Long-Acting
Bronchodilators
Cromolyn / Tilade
Increased heart rate, tremors,
headache (last short time)
Rare, may have throat irritation
Leukotriene Modifiers
GI upset
Inhaled Corticosteroids Thrush, dysphonia, high doses
may have systemic effects
Systemic
Many - Increased appetite,
Corticosteroids
stomachache, mood changes, fluid
retention, diabetes, osteoporosis
Quick Relief Medicines
 Act
fast, generally within 15-20 minutes
 Relaxes the smooth muscles around the
bronchial tubes
 Parents need to know how often child is using
 Must have available at all times
 Is only medicine that helps child breathe quickly
ASTHMA MEDICATIONS

Beta 2 agonists - bronchodilators
– Albuterol (Proventil, Ventolin)
– Pirbuterol (Maxair)
– Levalbuterol (Xopenex)
– Terbutaline (Brethine)
– Metaproterenol (Alupent)
Explain About Quick-Relief
Medications

Provider message:
–Quick-relief medications
relax the muscles after they
have tightened during an
attack
–Parents are in charge of
helping their children breathe
through the quick-relief
medications
–Quick- relief medications
act fast, so that breathing is
easy again within minutes

Parent Message:
–Know that medicines will
open up lungs and child
won’t suffocate
–Know that reaction is not
instant; may take a few
minutes
–Quick relief medicines are
parents’ ticket to helping
child breathe
Communication Tip for Quick-Relief
Medications
 Use
a physical example: Unclamp fist to show how
medicines work
 Ask parent about fears they have regarding child’s
asthma episode
 Discuss concerns parents may have about
medications
– Jitteriness; anxiety & other side effects parents may fear
(“dependence”)
 Be
accurate about risks but reinforce message that
medicines work!
Explaining about Long-term
Control Medications

Provider Message:
–Anti-inflammatory medicines
don’t relieve symptoms
–Do reduce inflammation and
prevent frequent or severe
episodes
–Needed if symptoms more
than 2X/week in day or
2X/month at night
–Effective only if taken
regularly

Parent Message:
–Anti-inflammatory meds
are like a flu shot, to help
keep away the “bad” asthma
episodes
–Anti-inflammatory
medicines are like vitamins;
they need to be taken all the
time, even if not sick
Communication Tips about Long-term
Control Medicines
Explain the different types of controllers (parents want to
know the names), and why more than one may be used
 Convey clearly information about any risks or side effects
 Discuss fears about medication “dependence”
– Low Doses of Inhaled Corticosteroids do not cause
side effects
– Not the same as the body-building steroids
 Emphasize safety of the medications when used as
prescribed on the plan.

ASTHMA MEDICATIONS
 Long-acting beta
2 agonists
– Salmeterol (Serevent)
– Formoterol (Foradil)
– Combine with ICS (ADVAIR available)

Inhaled (ICS)
Corticosteroids
–Beclomethasone (Vanceril,
Beclovent, Q-VAR)
–Budesonide (Pulmicort)
–Flunisolide (Aerobid)
–Fluticasone (Flovent,
ADVAIR)
–Triamcinolone acetonide
(Azmacort)

Systemic
–Prednisone/Prednisolone
–Methylprednisolone (SoluMedrol, Medrol)
ASTHMA MEDICATIONS

Mast cell stabilizers
– Cromolyn sodium (Intal)
– Nedocromil (Tilade)

Anticholinergic
– Ipratropium bromide
– (Atrovent)

Methylxanthines
– Theophylline
– Aminophylline
ASTHMA MEDICATIONS

Leukotriene inhibitors
– Oral, QD-BID
– Montelukast (Singulair)
– Zafirlukast (Accolate)
– Zileuton (Zyflo)
– Some evidence of effectiveness in preventing premenstrual
asthma exacerbations1
1. J Allergy Clin Immunol 1999;104:585-8.
Spacers/Holdin
g Chambers
Peak Flow Monitoring
 Provides
objective information
 Documents personal best
 Detects worsening asthma before changes
occur
 Useful only if breathing is monitored regularly
 Indicates need for quick-relief medications
 Assists in precipitant identification
 Aids in communication
Determine Personal Best Peak Flow
 Take
peak flow reading at least once per day for 2-3
weeks
 Measure peak flow at these times:
– Between noon and 2pm each day
– Each time quick-relief meds are taken for
symptoms
– Any other time your doctor suggests
 Use same peak flow meter over time
 Important Component of written action plan
Proper PF Technique
1- Set meter to Zero
2- Stand up straight
3- Take deep breath in
4- Blow out hard & fast
5- Repeat two more times
6- Record your highest number
Teaching Peak Flow
 Instruct
in how to establish child’s personal best
 Demonstrate to child/parent how to set child’s zones
(red, yellow & green)
 Help parent establish a routine for peak flow
measurements
 Remind parent to adjust medications according to
peak flow number
INTERNET SITE
 Guidelines
NHLBI/ WHO report
http://www.ginasthma.com
Cochrane Site:
http://www.cochrane.org/
 Clinical Evidence:
http://www.clinicalevidence.org
QUESTIONS ????
THANK YOU
WITH MY BEST REGARDS
Thank
You
PRACTICAL
GROUP (A)
- Simple clinical algorithm for
management of bronchial asthma
among ADULT in PHC clinic
 GROUP (B)
- Simple clinical algorithm for
management of bronchial asthma among
CHILDREN in PHC clinic
 Group (c)
- Simple clinical algorithm for
management of bronchial asthma in
EMERGENCY

REFERENCES and FURTHER
READINGS
The National Scientific Committee of
Bronchial Asthma in Saudi Arabia. The
National Protocol for the management of
Asthma, fourth edition1424/2003.
 National Heart, lung, and Blood Institute,
National Institute of Health. WHO
workshop report. Global Strategy for
Asthma Management and
Prevention,2002.
