4 Bronchial Asthma

7/29/2019 4 Bronchial Asthma

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INTERNAL MEDICINE LEC. #4 PART #2, 04-03-2013

P.S. DOCTOR SAID THAT HE WOULD SPEAK QUICKLY TO LET US UNDERSTAND AND ANSWER THE QUESTIONS IN THE EXAM , SO

THINGS HE DIDN'T MENTION YOU CAN GO BACK TO THE SLIDE TO READ THEM!

BRONCHIAL ASTHMA

Definition and Characteristics

It is a chronic inflammatory disorder of the

airways , its phenotypes or Causing

recurrent/intermittent episodes (attacks) of:

❍Wheezing

❍ Breathlessness

❍ Chest tightness

❍ Cough particularly more at night

Those Symptoms are worse at night and/or

in the early morning.

when we test their lung function the

Variable airflow limitation that is at least

partly reversible either spontaneously or with

treatment, in another words when we give

them bronchodilator drug they usually go back to normal.

Airway hyper-responsiveness to a variety of stimuli; for example when they smoke they

show symptoms Wheezing, Chest tightness & Cough.

The Scope of the Problem -USA

There is no good studies about asthma inJordan but it's very common, in USA it

Affects 14 -15 million people, 6% of children

under 18 years of age and adults having wide

range of age , Inner city children have



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highest rates bcz of pollution, Rates higher among females, Rates higher among blacks.

This study has been made to know what is population's experience with asthma for

example 35.1% of population have family member of asthma and almost 6% themselves

have asthma, So asthma is a common disease, it's unusual that there is some body don't

know anything about asthma almost 25% or less.

causative factors of asthma are:

Genetic : those who are born with atopy, and

others bcz of Environmental factors : allergy,

viruses, diet, antibiotics and smoking.

Pathophysiology of asthma

It's complicated multiple cells, multiple pathways

and multiple cytokines are involved in the end all of

these lead to :

❍Inflammation of airway

❍Airway hyper responsiveness❍Airflow obstruction

❍Bronchial injury

in this picture we can notice the difference

between the normal and asthmatic airways; where

the asthmatic one is narrowed, there is mucus

hyper secretion, smooth muscles hyperplasia, so it'snarrowed but not a mechanical narrow it's due to

thickening of the walls because of a disease so the

bronchodilators alone will not solve the problem.



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Consequences of events of Asthma:

in the figure beside, there is a stimulus like

allergies to flowers or grass in spring season which

lead to acute airway inflammation which with timebecome chronic inflammation and injury to the

airway and with frequent inflammation lungs will

try to protect themselves by remodeling of the

airways, so it's not a benign disease.

in the figure beside, the lungs function was measured

by FEV1, the curve above is determining the lung

function of normal person it drops with age , but in

the lower curve for the asthmatic one which drops

worse with age , indicating that it's not a benign

reversible disease.

We can notice that the curve is a step wise manner ,

the steps usually indicate acute exacerbation of the

asthma; whenever there is worsening of the disease

or acute exacerbation they use more function of thelungs.

Asthma is an inflammatory airway disease, has it's won stimulus, cause airway hyper responsiveness, has

symptoms, not benign in all patients some of them progress and lose their lung function with time.

popularly asthma is known as chronic lifelong

disease, if asthma onset occurs at younger ages

5 years for example the majority of them will

be remission and some of them will persist, but

if it occurs at late stages the majority will

persist and some of them will resolve or

remission. So the Onset of the disease will

detect what will happen at the end.



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Risk Factors for Asthma

Perinatal exposure to tobacco smoke, parents when they

smoke near their children they increase their risk of

asthma.so take this advice from Dr. "It's not a benign thing to

somebody to smoke in a KIA car with his wife and 5

children!!"

Atopy is associated with inherited elevation of total IgE

mediated to specific things like olive, house dust mite, ... ect.

Indoor Air Triggers, inside the house the most common is the

house dust mite ; which live on the dust we could see when sun

shine go through the window, we can inhale it to inter ourairways and other parts of our body, a lot of people are allergic

to this but it's very difficult to get rid of it bcz it's everywhere!

There are people allergic to Cockroaches, Animal dander (cats

and dogs), Environmental tobacco smoke

outdoor Air Triggers, olive is a common tree in Jordan bcz it's

easy to deal with so it presents everywhere and there are

somebody allergic to it.

Additional Triggers:

❍ Viral upper respiratory infections

❍ GERD (Gastroesophageal reflux disease)

❍ Sinusitis and rhinitis

❍ Diet, allergic to food

❍ Cold air

❍ Drugs, regarding the dentists almost the NSAIDs are

used, some patients of asthma die from one tablet or one injection of NSIAD, Beta

blockers for those with heart failure.



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Asthma Diagnosis

usually it is clinical diagnosis just doing :

❍History and patterns of symptoms.

❍Physical examination, office spirometry.

❍Measurements of lung function.

❍Measurements of allergic status to identify risk factors to a certain patient.

Symptoms and Signs

❍Variety of symptoms

*wheeze*shortness of breath

*chest tightness that

*cough

worse during night or early in the morning and also there is something called provoked by

triggers

❍Asthma symptoms tend to be:

*Variable and intermittent, go up and down

*Worse at night and early morning , and there is seasonal variation to those with seasonalallergy

*Provoked by triggers, because of their airway hyper responsiveness to factors like

smoke, perfume ,.. ect.

❍Additional Elements in History

Personal or family history of:

Asthma, Atopic condition: eczema, allergic rhinitis

Worsening of symptoms after:

*Exposure to recognized triggers

*Taking aspirin, NSAID, b-blockers. it's important as a dentist to ask the patient is he has

allergy to one of them.

*Exercise, they are ok but when they run they start coughing especially in children.



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In examination some patients look normal don't have any signs that doesn't mean they

don't have asthma, they may be normal during the day but get worse at night! but you

should hear wheezes.

Differential Diagnoses

what looks like asthma? those who have the same signs

and symptoms of asthma:

❍ COPD; this is a similar disease but in heavy smokers

with 50 or more years of age, who have more than 20

years back of smoking.

❍ Gastro-esophageal reflux disease (GERD); they have

cough during night.

❍ Cystic fibrosis; sputum production❍ Vocal cord dysfunction;

Diagnostic Tools

❍Peak flow monitoring by patients, a small instrument

measures the speed of the air exhalation of the patient,

for example measure the peak flow at morning it's 300

then at night it becomes 600 which is the variability that is

typical to asthma.❍Pulmonary function testing (spirometry)

1- Obstructive pattern

↓ Forced Vital Capacity (FVC)

↓ Forced Expiratory Volume in 1 second (FEV1)

FEV1/FVC < 70% to say that this patient is asthmatic.

2- Reversible airflow limitation

FEV1 increases by ≥ 15% after inhalation of a rapid-acting beta-2-agonistthat means the patient who has obstruction or he can't exhale all air from his lungs is

given a bronchodilator then measure the obstruction again , if he gets better by more

than 15% then he is asthmatic.



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Clinical Control of Asthma

Asthma at the past was a difficult disease to treat but now with discovery of newer

medications especially inhaled corticosteroids we can control asthma, in a large number

of patients they are completely normal they have:

✔ No (or minimal)* daytime

symptoms

✔ No limitations of activity

✔ No nocturnal symptoms

✔ No (or minimal) need for rescue

medication

✔ Normal lung function

✔ No exacerbations

_________

Minimal = twice or less per week

So it can be controlled , diagnosed

and treated appropriately.

# Usually we classify asthma according to the characteristics mentioned in the table

above; Controlled, partly controlled or Uncontrolled. then we can make adjustment to

the medication accordingly. But the main goal of us to get the patient to the left sided

column (controlled).

Asthma Management

Although there is no cure for asthma Appropriate management most often results in

the achievement of control, if it cured it will cure spontaneously.

Controller Medications1- Inhaled glucocorticosteroids , which is the most important one. 2- Leukotriene modifiers, it's name is montelukast in the market it can be effective

especially children

3- Anti-IgE , they are expensive can be very effective with some patients. 4- Theophylline



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5- Systemic glucocorticosteroids , used in severe cases. Long-acting inhaled β2-agonists

Reliever Medications

those medication are given to the patient in emergencies when we want a rapidresponse:

1- Rapid-acting inhaled β2-agonists : available in the hospital which is Salbutamol ,

available as tablet, syrup or inhaler.

2- Systemic glucocorticosteroids ,

used in acute exacerbation.

**a picture of inhalers we use :

** the table below just to knowthat there is step up step down

approach for the pulmonologist

to help them decide to increase

or decrease the dose of a drug.

Asthma Exacerbations

It's the same asthma but sometimes it get acute to

worse those have :

Episodes of progressive increase in shortness of

breath, cough, wheezing, or chest tightness

Characterized by decreases in expiratory airflow

Potentially life-threatening and treatment requires close supervision

there were patients who were dead because of asthma in the hospital! So Asthma is nota completely benign disease like many people think!

Manage Asthma Exacerbations

we use the same medication used to manage the chronic asthma but more intensively,

for example instead of giving inhaler we give metaboliser or IV.



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ORAL HEALTH CHANGES IN PATIENTS WITH ASTHMA

Increased rate of caries development

Reduced salivary flow

Oral mucosal changes

Gingivitis

Orofacial abnormalities (adenoid face)

Increased upper anterior and

total anterior facial height

Higher palatal vaults

Greater overjets

Higher prevalence of posterior crossbites

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☀☁【THE HAPPY END】☀☁ Done by :

Baraa'h Al-Salamat

4 Bronchial Asthma

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