BRONCHIAL ASTHMABRONCHIAL ASTHMA

prof. Mohammad Ali Khanprof. Mohammad Ali Khan MB, DCH, MRCP(UK)MB, DCH, MRCP(UK)

Head of paediatric departmentHead of paediatric departmentSIMS/Services Hospital,SIMS/Services Hospital,

Lahore.Lahore.

BRONCHIAL ASTHMABRONCHIAL ASTHMA

DefinitionDefinition

Reversible BronchospasmReversible Bronchospasm Hyper-reactivityHyper-reactivity VariabilityVariability Allergic DisorderAllergic Disorder

Chronic Inflammatory DisorderChronic Inflammatory DisorderMediated by eosinophils, IgE, mast cells and T-helper Mediated by eosinophils, IgE, mast cells and T-helper lymphocytes. These lymphocytes produce proallergic, lymphocytes. These lymphocytes produce proallergic, proinflammatory cytokines (IL4, IL5, IL13) and proinflammatory cytokines (IL4, IL5, IL13) and chemokines.chemokines.

PATHOGENESIS PATHOGENESIS

AntigenAntigen

Ist exposureIst exposure

II exposureII exposure

Y

Y

Ig E

Ca++ Ch.mediators

cAMP

GMP

ATP C,AMP MBPD

Theophylline

adrenergic

C h o l i n e r g I c

GMP

Adrenaline

Salbutamol

Albuterol

Salmetrol

Terbutalin

Ipratropium

Precipitating FactorsPrecipitating Factors

EndogenousEndogenous ????? ?????

ExogenousExogenous– AllergensAllergens (mostly inhaled)(mostly inhaled)– FoodFood– InfectionsInfections (mostly viral URTI)(mostly viral URTI)– ColdCold– ExerciseExercise– DrugsDrugs

Types of AsthmaTypes of Asthma

1.1. Triggered by InfectionsTriggered by Infections

2.2. Chronic asthma associated with Chronic asthma associated with allergyallergy

3.3. Asthma in obese girls with early Asthma in obese girls with early pubertypuberty

4.4. OccupationalOccupational

5.5. Triad asthmaTriad asthma

Clinical presentationClinical presentation

CoughCough

DyspnoeaDyspnoea

WheezingWheezing

Exercise intoleranceExercise intolerance

Chest deformityChest deformity

D/DD/Dasthma commonly wheeze asthma commonly wheeze

butbuteverything which wheeze is not everything which wheeze is not

asthmaasthma BronchiolitisBronchiolitis Bronchopneumonia or BronchitisBronchopneumonia or Bronchitis BPDBPD Foreign bodyForeign body Endobronchial tuberculosisEndobronchial tuberculosis Enlarged hilar L. nodes compressing upon the Enlarged hilar L. nodes compressing upon the

main bronchusmain bronchus BronchiectasisBronchiectasis Gastroesophegeal refluxGastroesophegeal reflux

InvestigationsInvestigations CBC, ESRCBC, ESR CXRCXR S. IgES. IgE Allergy testing Allergy testing Lung functionsLung functions

– FEV1 : FVC FEV1 : FVC <0.8 <0.8– Response to BronchodilatorsResponse to Bronchodilators >12% increase in >12% increase in

FEV1FEV1– PEFRPEFR

personal Bestpersonal Best Morning-to-evening variationMorning-to-evening variation >20% >20%

Exercise challengeExercise challenge– Worsening in FEV1 by >15%Worsening in FEV1 by >15%

ManagemenManagementt Acute exacerbationAcute exacerbation

Chronic asthmaChronic asthma

Goals Of ManagementGoals Of Management Maintain normal activityMaintain normal activity

Normal growthNormal growth

Prevent sleep disturbancePrevent sleep disturbance

Prevent chronic asthma symptomsPrevent chronic asthma symptoms

Keep asthma exacerbations from becoming severeKeep asthma exacerbations from becoming severe

Maintain normal lung functionsMaintain normal lung functions

Experience little or no adverse effects ofExperience little or no adverse effects of treatmenttreatment

Management Of Acute Management Of Acute AttackAttack

Q.Q. Does Asthma threaten life?Does Asthma threaten life?

A.A. Commonly not Commonly not

But sometimes But sometimes YES.YES.

((Mortality 0.3 /100,000 Mortality 0.3 /100,000 population /yr)population /yr)

IdentificationIdentification SevereSevere Resp ArrestResp Arrest

imminentimminentSymptomsSymptoms

DyspneaDyspnea At restAt restTalks inTalks in WordsWordsAlertnessAlertness AgitatedAgitated DrowsyDrowsy

SignsSignsDyspneaDyspnea ++++++ Paradoxical abd-Paradoxical abd-

thoracic thoracic movements.movements.WheezeWheeze ++++++ SilentSilentPulsePulse TachycardiaTachycardia BradycardiaBradycardiaP. paradoxisP. paradoxis >20-40 mm Hg>20-40 mm Hg AbsentAbsentcyanosiscyanosis ++++ ++++++

Functional AssessmentFunctional AssessmentPEFRPEFR <50<50PaO2PaO2 <60<60PaCO2PaCO2 >50>50SPO2SPO2 <90<90

Risk FactorsRisk Factors HistoryHistory

– Chronic steroid dependent asthmaChronic steroid dependent asthma– Prior ICU admissionPrior ICU admission– Prior mechanical ventilationPrior mechanical ventilation– Recurrent visits to ER during last 48 hrsRecurrent visits to ER during last 48 hrs– Poor compliance with therapyPoor compliance with therapy– Resp arrest/ hypoxic seizures or encephalopathyResp arrest/ hypoxic seizures or encephalopathy

Cl/ExamCl/Exam– Cyanosis.Cyanosis.– Hypotension/ pulsus paradoxis.Hypotension/ pulsus paradoxis.– Agitation/ drowsinessAgitation/ drowsiness– Quiet chestQuiet chest

LabLab– Hypercarbia, hypoxia,Hypercarbia, hypoxia,– CXR – Pneumothorax or pneumomediastinumCXR – Pneumothorax or pneumomediastinum

TherapyTherapy– Over-reliance on aerosol therapyOver-reliance on aerosol therapy– Delayed use of systemic steroidsDelayed use of systemic steroids– SedationSedation– Delayed admission to ICU.Delayed admission to ICU.

Management:Management:

1.1. O2 inhalationO2 inhalation

2.2. Inhaled Salbutamol/AlbuterolInhaled Salbutamol/AlbuterolNebulization or MDINebulization or MDI

3.3. Inhaled IpratropiumInhaled Ipratropium

4.4. Systemic steroidsSystemic steroids

5.5. Aminophylline infusionAminophylline infusion

6.6. Heliox (70:30 mixture)Heliox (70:30 mixture)

7.7. Mgso4 infusion (25 mg/kg in 20 min)Mgso4 infusion (25 mg/kg in 20 min)

8.8. Mechanical ventilation.Mechanical ventilation.

Management of Chronic Management of Chronic AsthmaAsthma

Drugs Used:Drugs Used:1.1. Beta-2 agonistsBeta-2 agonists

2.2. Non steroidal anti-inflammatory Non steroidal anti-inflammatory agentsagents

3.3. CorticosteroidsCorticosteroids

4.4. Slow release theophyllineSlow release theophylline

5.5. Leukotrine modifiersLeukotrine modifiers

Beta-2 AgonistsBeta-2 Agonists

Short ActingShort Acting– Salbutamol (ventolin)Salbutamol (ventolin) MDI, Neb,Oral,Inj.MDI, Neb,Oral,Inj.– Terbutaline (Bricanyl)Terbutaline (Bricanyl) MDI, Neb,Oral,Inj.MDI, Neb,Oral,Inj.

Long ActingLong Acting– Salmetrol (Serevent)Salmetrol (Serevent) MDIMDI

Non steroidal anti-Non steroidal anti-inflammatory agentsinflammatory agents

Sodium chromoglycate (Intal)Sodium chromoglycate (Intal)MDI, Spinhaler.MDI, Spinhaler.

CorticosteroidsCorticosteroids

InhaledInhaled– BeclomethasoneBeclomethasone MDI, MDI,

NebNeb(Becotide, Becloforte, Clenil A)(Becotide, Becloforte, Clenil A)

– BudesonideBudesonide MDIMDI(Pulmicort)(Pulmicort)

– FluticasoneFluticasone MDIMDI(Flixotide)(Flixotide)

SystemicSystemic

– PrednisolonePrednisolone

Dosage of inhaled Dosage of inhaled CorticosteroidsCorticosteroids

CorticosteroidsCorticosteroidsLow doseLow dose

ug/dayug/dayMedium doseMedium dose

ug/dayug/dayHigh doseHigh dose

ug/dayug/day

BeclomethasonBeclomethasonee

200-400200-400 400-800400-800 >800>800

BudesonideBudesonide 200-400200-400 400-800400-800 >800>800

FluticosoneFluticosone 50-20050-200 200-400200-400 >400>400

Leukotrine ModifiersLeukotrine Modifiers

Leukotrine Receptor AntagonistLeukotrine Receptor Antagonist– MonteleukastMonteleukast (Singulair)(Singulair)– ZafrileukastZafrileukast (Accolate)(Accolate)

Leukotrine InhibitorsLeukotrine Inhibitors– ZileutonZileuton

Slow Release Slow Release TheophyllineTheophylline

TheodurTheodur

TheogradTheograd

Step-wise ApproachStep-wise Approach

Asthma Asthma SeveritySeverity

Days Days with with sympt-sympt-omsoms

Nights Nights with with symptomsymptomss

FEV1/FEV1/

PEFRPEFR Control MedicationControl MedicationRelief Relief MedicaMedicatt

-ion-ion

EducEducationation

IIMild Mild intermitteintermittentnt

<3/wk<3/wk <3/ mo<3/ mo >80>80 No medicationNo medication

SABASABA

IIII

Mild Mild persistentpersistent

>3/wk>3/wk 3-4/ mo3-4/ mo >80>80 Inhaled steroids (low dose)Inhaled steroids (low dose)LABALABALeukotrines modifiersLeukotrines modifiers

SABASABA

IIIIII

ModerateModerate

persistentpersistent

DailyDaily >1/ wk>1/ wk 60-60-8080

Inhaled steroids (medium Inhaled steroids (medium dose)dose)LABALABALeukotrines modifiersLeukotrines modifiersSustained release Sustained release theophyllinetheophylline

SABASABA

IVIV

SevereSevere

persistentpersistent

Contin-Contin-ual ual

sympt-sympt-omsoms

frequentfrequent <60<60 Inhaled steroids (high dose)Inhaled steroids (high dose)LABALABALeukotrines modifiersLeukotrines modifiersSustained release Sustained release theophyllinetheophyllineOral steroidsOral steroids

SABASABA

Rule of ‘3’Rule of ‘3’

1.1. Asthma symptoms orAsthma symptoms or >3 times/wk>3 times/wk

need for bronchodilatorsneed for bronchodilators

2.2. Awakes at night becauseAwakes at night because >3 >3 times/mthtimes/mth

of asthmaof asthma

3.3. Consumption of Consumption of >3/year>3/year

bronchodilator inhalerbronchodilator inhaler