Asthma by Reshma

8/6/2019 Asthma by Reshma

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Bronchial Asthma Presented by



Asthma Asthma is characterized by hyperresponsiveness of tracheo

bronchial smooth muscle to a variety of stimuli resulting

in narrowing of air tubes often accompanied by

Increased secretion,

Mucosal edema

Mucus plugging

Cough

Bronchospasm

Dysapnea

Wheezing.

Shortness of breath

Chest tightness



Pathogenesis of asthma

Exposure to stimuli/ allergens/ specific condition

Production of antibody (IgE)

Release of vasoconstrictor and inflammatory substances by mast cells

Inflammation and vasoconstriction

Migration of Phagocytic cells

Enhanced mucus secretionPhagocytosis

Release of basic lytic Air way narrowing & obstructionenzymes

Further inflammation Precipitation of asthma



Asthma Pathological Change

4



T ypes Of Asthma

Extrinsic (allergic) asthma :

More prevalent in the younger age group

It is caused by the immune system¶s response to inhaled allergens.

It responds quite well to the use of inhaled steroids as these suppress theimmune system

Intrinsic (non-allergic) asthma :

It is caused by anything except an allergy.

It may be caused by an infection, stress, laughter, exercise, cold air, food

preservatives or a host of other factors.

Occupational asthma :

Occurs due to a trigger in the place of work . Common triggers include pollutants

in the air, such as smoke, chemicals, fumes, dust, or other particles.



T ypes Of Asthma

Sports asthma/Exercise-induced asthma :

Shortness of breath and coughing occurring after an exhausting exercise is termed

exercise-induced asthma.

Occur about 5-20 minutes after beginning an exercisePrecautions include using a bronchodilator inhaler just prior to the sports activity.

Drug induced asthma :Special type of intrinsic asthma.acute asthma attacks on first and subsequent exposure to aspirin and NS AID



I nvestigation / Diagnosis

1. Patient¶s history and the symptoms being displayed

2. Patient¶s family history should not be neglected, as it has a strong chance of

influencing the patient

3. A physical examination of the upper respiratory tract, Using a nasal mirror, look

inside the nose for signs of allergic disease such as increased nasal secretions,

swelling. These signs may suggest that allergies are responsible for triggering

suspected asthma.

4. Use a stethoscope to listen to the sounds the lungs make while breathing.

Wheezing sounds indicate one of the main signs of asthma: obstructed airways.

5. Finally, examine the skin for signs of allergic conditions such as eczema or hives,

which are often associated with asthma.



I nvestigation / Diagnosis Conti«

6. Spirometry ± Breathing Test

Spirometry measures three values that are important in

diagnosing asthma:

a) Vital capacity (VC), which is the maximum amount of air thatone can inhale and exhale

b) Peak expiratory flow rate (PEFR), also known as the peak

flow rate, which is the maximum flow rate one can generate

during a forced exhalation

c) Forced expiratory volume (FEV1), which is the maximumamount of air you one exhale in one second

If certain key measurements are below normal for a

person your age, it may be a sign that the airways are

obstructed



I nvestigation / Diagnosis Conti«.

7 Challenge test - During this test, a deliberate attempt is made to trigger airway

obstruction and asthma symptoms by inhaling an airway-constricting chemical or

taking several breaths of cold air.

8 Chest and sinus X-rays.

9 The doctor may also test a person¶s pulmonary function after administering him

some asthma medication. This helps confirm that the blockage in the air passagesthat shows up on pulmonary function tests goes away with treatment.



Person is asthmatic

Making a diagnosis of asthma :

� FEV115% (and 200 ml) increase following administration of a

bronchodilator/trial of corticosteroids� >20% diurnal variation in PEF on 3days in a week for 2 weeks

� FEV1 15% decrease after 6 mins of exercise

Predicted Values Measured

Values

% Predicted

FVC 6.00 liters 4.00 liters 67 %

FEV1 5.00 liters 2.00 liters 40 %

FEV1/FVC 83 % 50% 60%



T he goals of asthma management treatment

Achieve and maintain control of symptoms

Prevent asthma exacerbations

Maintain pulmonary function as close to normal as possible

Avoid adverse effects from asthma medications

Prevent development of irreversible airflow limitation

Prevent asthma mortality



1. Avoidance of aggravating factors

2. Use pharmacologic agents

a) Quick relief medications :

Bronchodilators that inhibit smooth-muscle contraction -Adrenergic agonists

Methylxanthines

anticholinergics

b) Long term control medications :

agents that prevents or reverse inflammation

Glucocorticoids

M anagement of asthma

leukotriene inhibitors

receptor antagonists

mast cell-stabilising agents



Quick Relief Medications or Bronchodilators :

Bronchodilators relaxing the airway muscle, so opens the airways, as a result,

breathing improves.

Bronchodilators also clear mucus from the lungs.

1) -Adrenergic agonists :

a. Short-acting inhaled form :

These are also called "quick acting or rescue" medications

These inhalers are the best for treating sudden and severe or new asthma

symptoms.

They work within 20 minutes and last four to six hours.

Available as inhalers as well as pills

M edication used in Asthma



M edication used in Asthma

b. Long-acting forms of beta 2-agonists :

Used to control asthma.

These drugs take longer to show effect, but their benefits last longer, even up to

12 hours.

They are available as inhalers as well as pills.

When the long-acting beta-adrenergic agonists are used together with inhaled

corticosteroids, better results are obtained.

Side effects of beta 2-agonists include :

Nervous or shaky feeling

Overexcitement or hyperactivity

Increased heart rate



2) Anticholinergic drugs :

These are used to control asthma.

It is available in both a metered-dose inhaler and a nebuliser solution.

Anticholinergic drugs take about 60 minutes before they start working.

They work best when used with a short-acting beta 2-agonist inhaler.

Doctors use anticholinergic drugs mainly in the emergency situations in

combination with a beta-2 agonist. When used alone, anticholinergics are only

marginally effective.

Side effects are minor, with dry throat being the most common.



3) Theophylline drugs :

Available as an oral (pill and liquid) or intravenous drug.

Theophylline and various salts; adjust dose to maintain blood level between 5

and 15 g/ mL; IV (as aminophylline).

Theophylline clearance varies widely and is reduced with age,

hepatic dysfunction, cardiac decompensation, cor pulmonale.

Many drugs also alter theophylline clearance (decrease half-life: cigarettes,

phenobarbital, phenytoin; increase half-life: erythromycin, allopurinol,

cimetidine, propranolol).Side effects include:

Nausea, Diarrohea, Imsomnia, Headache, Irregular heartbeat, Muscle cramps,

nervous feeling.

These symptoms may be a sign of having taken too much medication hence important

to check your blood levels.



Long term control medications :

1)Glucocorticoids

Systemic or oral administration are most beneficial.

Not useful in acute asthma.

For exacerbations of asthma in the outpatient setting, prednisone 40 ±60 mg PO

daily

Agents available include beclamethasone, budesonide, flunisolide, fluticasone

proprionate, and triamcinolone acetonide. In addition to local symptoms, systemic effects may occur (e.g., adrenal

suppression, cataracts, bone loss).

Combination of an inhaled steroid (fluticasone) and 2 agonist (salmeterol) is

gaining widespread use



2) Cromolyn sodium and nedocromil sodium :

Useful in chronic therapy for prevention, not useful during acute attacks Because

the drugs may block acute bronchoconstriction when administered 15 ±20 min

before exposure to antigens, chemicals, or exercise, they may be of use in

selected patients who have predictable attacks of extrinsic asthma (exerciseinduced).

Administered as metered-dose inhaler or nebulized powder, 2 puffs daily.

3) Leukotriene modifiers :

They are anti-inflammatory drugs, which prevent the synthesis of leukotrienes

(chemicals made by the body that cause bronchoconstriction).

These drugs, orally taken, are used to prevent asthma attacks rather than treat

them, but can be used during an attack as well.



I nhaled Asthma M edication

Four Classes Of Asthma Drugs:

1. 2 Agonists

2. Anticholinergics

3. Cromoglycate

4. Glucocorticoids

Aerosol are of two types

1) Use drug in solution : metered dose inhaler,nebulizer

2) Use drug dry as powder : spinhaler, rotahaler



Step up Therapy :

Step 1 : Occasional use of inhaled short-acting 2 adrenoreceptor

agonist bronchodilators

Inhaled short acting 2-agonist used in patients with mild intermittent

asthma (symptoms less than once a week for 3 months and fewer than two

nocturnal episodes per month)

Step 2 : Introduction of regular preventer therapy

Regular anti-inflammatory therapy (preferably ICS) should be started in additionto inhaled 2-agonist in patient who :

has experienced an exacerbation of asthma in last 2 years uses inhaled 2-

agonist 3 times a week or more reports symptoms 3 times a week or more

is awaken by asthma one night per week.

A stepwise approach to the management of asthma




Starting dose is 400g Beclometasone dipropionate (BDP) per day in adult

BDP and budesonide (BUD) are approximately equivalent

Fluticasone and mometasone provide equal clinical activity to BDP/BUD at half the

dosage.

Step 3 : Add ± on therapy

If patient remains poorly controlled despite regular use of ICS A further increase in the

dose of ICS may benefit Add on therapy should be considered beyond an ICS dose of

800g/day BDP in adults Long acting 2-agonist (LAB A), salmeterol and formoterol(duration of action of at least 12 hours) LAB A improve asthma control and reduce the

frequency and severity of exacerbation copare to increased dose of ICS alone.




Combination inhalers of ICS and LAB As have been developed. Adv- more convenient,

increase compliance.Leukotriene receptor antagogonists (e.g. monteleukast 10mg daily)

are a relatively new class of agents, delivered orally.Theophyllines may be useful in

some patients but their unpredictable metabolism, drug interactions, side effects have

limited their use.

Step 4 : Continuous or frequent use of oral steroids

At this stage Prednisolone therapy (usually administered as a single daily dose in

morning) is given to control the symptoms. Patients receiving corticosteroid tablets for more than 3 months or receiving more than 3-4 courses per year will be at risk of

systemic side-effects.




Step down therapy :

Once asthma control is established, the dose of inhaled (or oral)

corticosteroids should be reduced to lower dose at which effective control of asthmais maintained.



Exacerbations of Asthma :

Exacerbations are characterized by-

# increased symptoms

# deterioration in Peak expiratory flow

# increase in airway inflammation

Exacerbations may be precipitated by-

# infections ( most commonly viral)

# moulds ( Alternaria and Cladosporium)

# pollens (particularly following thunderstorm)

Management of mild-moderate exacerbations :

Short courses of µrescue¶ oral corticosteroids (prednisolone 30-

60mg daily) used to regain control of symptoms. withdraw

treatment, after using for more than 3 weeks.



Acute severe asthma

PEF 33-50% predicted (<200 l/min)

Respiratory rate � 25/min

Heart rate �110/min

Inability to complete sentence in 1 breath

Life-theatening features

PEF 33-50% predicted (<200 l/min)

SpO2<92% or PaO2<8k Pa (60mmHg), Normal PaCO2

Silent chest

Cyanosis

Feeble respiratory effort

Bradycardia or arrythmias

Confusion

Coma

Near-fatal asthma

Raised PaCO2 &/or requiring mechanical ventilation

Acute severe asthma :

Initial assessment



1. Oxygen :

High concentration of oxygen (humidified if possible) to maintain the oxygen saturation

above 92% in adults.

Failure to achieve appropriate oxygenation is an indication for assisted ventilation.

2. High doses of inhaled bronchodilators :

Short acting 2-agonist administered via a nebulizer driven by oxygen

Multiple doses of salbutamol via a metered dose inhaler through a spacer

Combination of salbutamol and ipratropium bromide

3. Systemic corticosteroids :

Administered orally Prednisolone 30-60mg

IV hydrocortisone 200mg

M anagement of acute severe asthma



4. Intravenous fluids :

Potassium supplements may be necessary because repeated doses of salbutamol can

lower serum potassium

Subsequent management :IV magnesium may provide additional bronchodilator in patients whose presenting PEF

is <30% predicted

Use of IV leukotriene receptor antagonists

Monitoring of treatment :

PEF should be recorded every 15-30min and then every 4-6 hrs.Pulse oximetryb should ensure that SaO2 remains >92%



Antiasthmatic Combinations

1) BRONKOPLUS : salbutamol 2mg, anhydrous theophylline

100mg tab.,also per 5ml syrup.

2) BRONKOTUS: Bromohexine 4mg, salbutamol 2mg tab,.alsosyrup- bromohexine 4mg,salbutamol2mgper 5ml

3) TER PHYLI N: Terbutaline 2.5mg, etophylline100mg tab.

4) THEO ASTHLI N : Salbutamol 2mg, theophylline anhydrous100mg tab.

5) THEO BR IC: Terbutaline 5mg, theophylline 100mgtab.



Case Study

Que. Mr. PG is a 42 ±years-old recently diagnised asthamatic. He is

non-smoker. He has been measured his PEF regularly since diagnosis

and has a morning-to-night diurnal variation of between 380 and 500

L/min(his best value) His current medication is:* beclometasone pressurized MDI 200g twice a day

* salbutamol pressurized MDI 200 g when required

He comes to you for his next review. During your discussion, Mr PG

tells you that he has noticed that he is wheezing more at night than previously and wakes up two or three times a night. He is also

affected by cold air whilst walking to work, necessitating the use of

his salbutamol most mornings



Case Study

Ans.



Case study

ue. Mrs JS is attending the hospital respiratory outpatient clinic, 3 weeks after her

fourth hospital admission for exacerbation of her asthma in a year. She is 44 and

has been diagnosed with asthma since the age of 4

Her current medication is:* salbutamol pressurized MDI 2 puffs when required

* seretide-250 pressurized MDI 2 puffs twice a day

* prednisolone tablets 8 mg once daily

* theophylline M/R 500mg twice daily

* methotrexate tablets 10mg once a week.

She has required oral steroids in addition to her seretide for 3 years; she started at

15mg daily and is now reduced to 8mg. She has been talking the methotrexate for

3 months but has not managed to reduced her oral steroid dose. She has also tried

oral ciclosporin in the past year to try and help reduced this, with no effect.



Case study

Ans.



� www.wikipedia.com

� K.D. Tripathi, Essentials of medical

pharmacology, jaypee brothers publishers,6th

edition,pp.216-227.

� Roger walker,Cate whittlesea, Clinical

Pharmacy and Therapeutics,Fourth edition,

pp.367-384.

�

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