Asthma oct 2016

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ASTHMA

We will start with 2 case presentations.I would like to see your information about asthma1

CASE No 1 age: 66Dan B. Pascaru

HTA from age 45AmlodipinePerindopril

Case No 1Stopped medication in january 2013

CASE No 1

Symptoms (2 days)CoughingDyspneea

Signs:WheezingCrackles

CASE No 1

Symptoms (2 days)CoughingDyspneea

Signs:WheezingCrackles

DIAGNOSIS

Sustain your clinical diagnosis6

DIAGNOSIS

ACUTE EXACERBATION OF ASTHMA ?

Sustain your clinical diagnosis7

Laboratory Tests ?FIRST LINE

SECOND LINE

Laboratory Tests FIRST LINE

Complete blood countBiochemistryCoagulation

Arterial Blood GasesBNP

SECOND LINE

Sputum examination



Arterial Blood GasesBNP = 12.000

SECOND LINE

Sputum examination

I will tell you only the value of BNP and you will tell me if this is CF or Asthma10

Beta2 mimetics ! prof

TachycardiaArrhytmiasMyocardial ischemia

Prin efectul beta 111

Case No 2age: 16Melinda Pascaru

History of asthma

2 crisis at age of 14

2 crisis/year

No medication

His daughtert12

Case No 2

Symptoms (2 hours)tachypneaacute shortness of breath audible wheezing

I feel like a fish out of water

Signs:WheezingHR 110, RR 40

No signs on physical examiation

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DIAGNOSIS

ACUTE EXACERBATION OF ASTHMA ?

DIAGNOSIS: ASTHMAMild ? Moderate ? Severe ?

What form ?There is a clasification of Asthma

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Laboratory Tests ?FIRST LINE

SECOND LINE




SECOND LINE

Sputum examination




SECOND LINE

Sputum examination

Complete blood count

Hb=12,7WBC=7000Pl=230.000Eosinophil count=15% N=(1-4%)

ESR=14 mm (N=0-9mm)CRP=NFbg=N

Paraclinical Tests FIRST LINE

EKGChest radiographEchocardiography

SECOND LINE

Spirometry



SECOND LINE

Spirometry



SECOND LINE

Spirometry




SECOND LINE

Sputum examination

Arterial Blood Gases

pH PaCO2 HCO3- PaO2 (Slightly)

pH= 7.5, PaCO2= 27, HCO3- =22 PaO2= 75

Hyperpneea elimination of CO2 PaCO2=35-45HCO#=24-27PaO2>80pH 7,35-7,45 RESPIRATORY ALCALOSISgreater than 110 indicates pt is on supplemental oxygen.26



Arterial Blood GasesBNP=120

SECOND LINE

Sputum examination

ASTHMA

DEFINITIONChronic or acute disease ?

DEFINITIONCommon chronic disorder of the airwaysCharacterized by Variable and recurring symptomsAirflow obstructionBronchial hyperresponsivenessAnd underlying inflamation

In a class of 30 children, you can expect 2 to 3 students WILL have asthma

EtiologyExtrinsic asthmaAllergic or atopic asthmaIntrinsic asthmaNonallergic or nonatopic asthma

PATOPHYSIOLOGY

Anatomic Alterations of the Lungs

Smooth muscle constriction of bronchial airways (bronchospasm)Excessive production of thick, whitish, tenacious bronchial secretionsHyperinflation of alveoli (air-trapping)Mucus plugging and, in severe cases, atelectasis

Figure 13-2. The immunologic mechanisms in asthma.

Intrinsic Asthma(Nonallergic or Nonatopic Asthma)InfectionsExercise and cold airIndustrial pollutants or occupational exposureDrugs, food additives, and food preservativesGastroesophageal refluxSleep (nocturnal asthma)Emotional stressPremenstrual asthma

PHYSICAL EXAMINATION

usually, the cough is nonproductive and nonparoxysmal.-children with nocturnal asthma tend to cough after midnight and during the early hours of morning.

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Vital signsIncreased respiratory rateIncreased heart rate, cardiac output,blood pressureClinical Data

Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.

Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.

Chest assessment findingsExpiratory prolongationDecreased tactile and vocal fremitusHyperresonant percussionDiminished breath soundsDiminished heart soundsWheezing and rhonchiClinical Data

in the mildest form, wheezing is only end expiratory.

in a more severe asthmatic episode, wheezing is also present during inspiration.

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Use of accessory muscles of inspirationUse of accessory muscles of expirationPursed-lip breathingSubsternal intercostal retractionsIncreased anteroposterior chest diameter (barrel chest)CyanosisCough and sputum productionPulsus paradoxusClinical Data

Obtained at the Patients BedsideOther signs47

Pulsus paradoxusDecreased blood pressure during inspirationIncreased blood pressure during expirationClinical Data

Severe asthma48

NONPULMONARY MANIFESTATIONS

Signs of atopy or allergic rhinitis

Skin atopic dermatitis, eczema, or other manifestations of allergic skin conditions.

LABORATORY TESTS




SECOND LINE

Sputum examination




SECOND LINE

Sputum examination

COMPLETE BLOOD COUNT

Blood eosinophilia greater than 4% or 300-400/L is consistent with the diagnosis of asthma, but

a normal value is not exclusionary.

IgE >100 IU patients with allergic reactions

test for allergic sensitivity : allergy skin tests (Prick test)

blood radioallergosorbent tests (RAST).

Total serum immunoglobulin E levels greater than 100 IU are frequently observed in patients with allergic reactions. Two methods are available to to specific allergens in the environment54



SECOND LINE

Pulmonary Function Study



SECOND LINE

Pulmonary Function Study

Radiologic FindingsChest radiograph

NormalHyperinflationIncreased anteroposterior diameterTranslucent (dark) lung fieldsDepressed or flattened diaphragm

Figure 13-4. Chest X-ray of a 2-year-old patient during an acute asthma attack.


Complete blood countEKGChest radiograph


SECOND LINE

Sputum examination

ABG

pH=7,35-7,45paCO2=35-45mmHgSaO2=93-98%paO2=80-100mmHgHCO3=24-26mEq/l

Time and Progression of Disease1005030800PaCO2

102040

Alveolar Hyperventilation607090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease Onset

PaO2 or PaCO2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.

Arterial Blood GasesMild to Moderate Asthma EpisodeAcute alveolar hyperventilation with hypoxemia pH PaCO2 HCO3- PaO2 (Slightly)

Time and Progression of Disease1005030800

PaO2

102040

Alveolar Hyperventilation607090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO2

Acute Ventilatory Failure

Disease Onset

Point at which disease becomes severe and patient begins to become fatigued

Pa02 or PaC02Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.

Arterial Blood GasesSevere Asthmatic Episode (Status Asthmaticus)Acute ventilatory failure with hypoxemia pH PaCO2 HCO3- PaO2 (Significantly)


Complete blood countEKGChest radiograph


SECOND LINE

Pulmonary Function StudySputum examination

ratio

RESTRICTIVEOBSTRUCTIVE

NORMAL

OBSTRUCTION

AFTER BRONCHODILATOR

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SECOND LINE

Sputum examination

Sputum examination

EosinophilsCharcot-Leyden crystals (see next slide)Casts of mucus from small airwayscalled Kirschman spiralsIgE level (elevated in extrinsic asthma)

Charcot-Leyden Crystals Needle shaped crystals -Represents breakdown products of eosinophils

DIFFERENTIAL DIAGNOSISLEFT HEART FAILURE

COPD

-Gastroesophageal reflux- Obstruction of the upper airways and inhalation of foreign bodies- Dysfunction of the vocal cords- Non-obstructive pulmonary diseases (diffuse interstitial pneumopathy)- Pulmonary thromboembolism- Hyperventilation syndrome and panic attack.

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HEART FAILURE

COPD

Pulmonary Function Testing

-the degree of reversibility in FEV1 which indicates a diagnosis of asthma is generally accepted as

12% and

200 ml

from the pre-bronchodilator value the administration of a short-acting bronchodilator.

PARACLINICAL EXAMINATIONS

ASTHMA-COPD

Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

Figure 9-11. Excessive bronchial secretions clinical scenario.

GINAFEV 1 > 80%

GINAFEV 1 > 80%FEV 1 > 80%

GINAFEV 1 =60- 80%FEV 1 > 80%FEV 1 > 80%

GINAFEV 1 =60- 80%FEV 1 80%FEV 1 > 80%

TREATMENT

1. Wich of the folowing are clinical findings in asthma ?

WheezingRetrosternal thoracic Pain Diminished breath sounds at auscultationDecreased heart rate (bradycardia)Hepatomegaly, jugular distension and edema

2. In asthma, laboratory tests show:

Elevated BNP > 12.000Increased anteroposterior diameter in X-rayElevated pH in mild to moderate asthmarestrictive respiratory disfunction in spirometryThrombus in right pulmonary artery

3. What is the treatment for acute asthmatic chrisis ?

Symbicort 3-4 times a daySpiriva 1/daySalbutamolOxygenIntravenous Amynophiline

TREATMENT

Reduce trigers of asthma

Being overweight can worsen astma symptoms95

Case No 2age: 16Melinda Pascaru

History of asthma

age 12, 14

No medication

His daughtert96

TREATMENT123456

bronchospasmanticholinergicsmethylxanthinesbeta2 simpaticomimeticsInflamation and edemaglucocorticosteroids

Mastocite degranulation Phosphodiesterase-4 inhibitors

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45Leukotriene inhibitors6



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BRONCHOSPASM

anticholinergicssimpaticomimeticsmethilxantines

23vegetativdirect



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Beta2 agonistsShort-acting

FENOTEROLSALBUTAMOLTERBUTALINELong-acting

FORMOTEROLSALMETEROL

1

4 hours12 hours

Neselective: adrenalina alfa=beta, isoprenalina beta1 si beta2Selective-cele enumerate beta2>> beta1BEROTEC VENTOLINBRYCANILREMINDER: Bronchodilators relieve symptoms but cannot reduce or prevent the swelling of airways that cause the symptoms.

Debutul efectului la 5 minute dureaza 4 ore 4 doze/zi.

OXIS TURBUHALERSEREVENT Debutul efectului la 3 ore dureaza 12 ore nu in acut ci in tratamentul cronic si profilaxia crizelor de astm ex: astmul indus de effort.

108

Beta2 agonistsShort-acting

FENOTEROL =BEROTECSALBUTAMOL =VENTOLINTERBUTALINE =BRYCANILLong-acting

FORMOTEROL=OXIS TURBUHALERSALMETEROL=SEREVENT

1

4 hours3 hoursSELECTIVES5 min12 hours

Neselective: adrenalina alfa=beta, isoprenalina beta1 si beta2Selective-cele enumerate beta2>> beta1BEROTEC VENTOLINBRYCANILREMINDER: Bronchodilators relieve symptoms but cannot reduce or prevent the swelling of airways that cause the symptoms.

Debutul efectului la 5 minute dureaza 4 ore 4 doze/zi.

OXIS TURBUHALERSEREVENT Debutul efectului la 3 ore dureaza 12 ore nu in acut ci in tratamentul cronic si profilaxia crizelor de astm ex: astmul indus de effort.

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123


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AnticholinergicsShort-acting

IPRATROPIUM BROMIDE

OXITROPIUM BROMIDELong-acting

TIOTROPIUM

2

IPRAVENT=ipatropium bromideATROVENT Efect in 15 minute, durata 6 ore

SPIRIVA 24 ore deci nu se foloseste in urgenta111

AnticholinergicsShort-acting

IPRATROPIUM BROMIDE=IPRAVENT

OXITROPIUM BROMIDE=ATROVENTLong-acting

TIOTROPIUM =SPIRIVA

2

24 hours6 hours

IPRAVENT=ipatropium bromideATROVENT Efect in 15 minute, durata 6 ore

SPIRIVA 24 ore deci nu se foloseste in urgenta112



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MethylxantinesShort-acting

AminophylineLong-acting

Theophyline (SR)

3

200 mg de 2 ori/ zi la copii si adolescenti 350 mg Theotard de 2 ori/zi114

MethylxantinesShort-acting

Aminophyline =MIOFILINLong-acting

Theophyline (SR)

3

200 mg de 2 ori/ zi la copii si adolescenti 350 mg Theotard de 2 ori/zi115



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GlucocorticosteroidsSystemic

PrednisoneMethyl-prednisoloneInhaled

Beclomethasone=BECOTIDEBudesonide=PULMICORTFluticasone=FLIXOTIDE

4

HHC in acute formLong action

BECOTIDEPULMICORTFLIXOTIDE

Doar pt tratament de intretinere

Oral:are used for short-term treatment (3-10 d) to gain prompt control of inadequately controlled acute asthmatic episodes.

I.V. corticosteroids are used in the acute phase of asthma.

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Phosphodiesterase-4inhibitors

CromolynNedocromil

5

INTALTILADE119

Phosphodiesterase-4inhibitors

Cromolyn =INTALNedocromil=TILADE

5

INTALTILADE120



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Leukotriene -inhibitors

Montelukast ZafirlukastZileuton

6

SINGULAIR 1/zi oralyACCOLATE 2/zi oralyZyflo 4/zi oraly122

Leukotriene -inhibitors

Montelukast =SINGULAIR Zafirlukast=ACCOLATEZileuton=ZYFLO

1/day2/day4/day

6

SINGULAIR 1/zi oralyACCOLATE 2/zi oralyZyflo 4/zi oraly123

COMBINATIONS in one inhalerShort-acting 2 agonist plus anticholinergic

FENOTEROL+IPRATROPIUM

SALBUTAMOL+IPRATROPIUMLong-acting 2 agonist plusglucocorticosteroids

FORMOTEROL+BUDESONIDE

SALMETEROL+FLUTICASONE

Nu sunt cu durata lunga beta2 si anticolinergic

SERETIDE25/50 microgr25/125 microgr25/250 microgr

Cele long-acting nu sunt eficiente in acut

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COMBINATIONS in one inhalerShort-acting 2 agonist plus anticholinergic

FENOTEROL+IPRATROPIUM= BERODUAL

SALBUTAMOL+IPRATROPIUM=COMBIVENTLong-acting 2 agonist plusglucocorticosteroids

FORMOTEROL+BUDESONIDE=SYMBICORT

SALMETEROL+FLUTICASONE=SERETIDE

25/50 25/125 25/250

Nu sunt cu durata lunga beta2 si anticolinergic

SERETIDE25/50 microgr25/125 microgr25/250 microgr

Cele long-acting nu sunt eficiente in acut

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Others

MucoliticsAntibiotics

OxigenSodium bicarbonate

Beta2 mimetics !

TachycardiaArrhytmiasMyocardial ischemia

Prin efectul beta 1128

OMALIZUMABMonoclonal antibody against IgEExpensive and requires monthly injectionsMost effective if allergies trigger asthmaChildren with documented allegriesNot for children without allergies

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AN ACUTE EPISODE

Acute episodes can be mild, moderately severe, severe, or characterized by imminent respiratory arrest.

ASTHMATIC CRISYS TREATMENT?????

ASTHMATIC CRISIS TREATMENT1)Beta2 mimetics (VENTOLIN)2)ATROVENT (IPRATROPIUM BROMIDE)3)AMYNOPHILINE (Miofilin 1-1-1 inj//day)4) HHC 100mg (1-0-1 inj/day)5)______6)______

ASTHMATIC CRISIS TREATMENTOxygenAntibiotics : Ampiciline, Cefalosporines, QuinolonesMucolitics: water, Acetilcisteine 3/day, Bromhexine.

ADRENALINE 0,3-0,5 ml Prednisone 30-40 mg/day < 5 mg/5 daysMechanical ventilation

CHRONICAL TREATMENT1)Long acting beta 2 mimetics: Serevent2)___________COPD3)Teotard4) inhaled glucosteroids: Becotide, Pulmocort, Flixotide5) Cromolyn, Nedocromil6)Leukotriene inhibitors: Singulair, zafirlukast, Zileuton

cromones

R

You must know that asthmatics can play sportsThere are many asthmatics players: David Backhamp140

And dont forget Mark Spitz who won 7 gold medals in swimming in the same Olimpics who was also asthmatic.141

Asthma oct 2016

Health & Medicine

Transcript of Asthma oct 2016