Asthma presentation2011

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Treatment of asthma; basics can save lives!

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  • 1. Dr M. Dikgang
  • 2. Chronic inflammatory disease of airways Increased responsiveness of tracheobronchial tree Multiplicity of stimuli Episodic disease Narrowing of airways (acutely and gradually), relieved spontaneously or after therapy.
  • 3. Risk Factors (for development of asthma) INFLAMMATIONAirwayHyperresponsiveness Airflow Obstruction Risk Factors Symptoms (for exacerbations)
  • 4. Asthma is one of the most common chronic diseases worldwide 160 million patients suffer from asthma Prevalence increasing in many countries, especially in children 1~4% in adult, 3~5% in children in China A major cause of school/work absence An overall increase in severity of asthma increases the pool of patients at risk for death
  • 5. Worldwide Variation in Prevalence ofAsthma SymptomsInternational Study ofAsthma and Allergies inChildren (ISAAC)Lancet 1998;351:1225
  • 6. Environmental Genetic factors factors MixedAtopic factors Non-asthma atopic/idiosyncratic asthma Early onset Late onset
  • 7. Stimuli: Allergens (mites, fur, feathers,molds etc) Pharmacological (NSAIDS, B-blockers etc) Environmental (NO2, sulphur dioxide) Occupational (wood/vegetable dust,pharmaceuticals etc) Infections (viruses-RSV, para-influenza) Exercise Emotional stress (vagal efferent activity, endorphins)
  • 8. Gross overdistention of lungs, non-collapsible Gelatinous plugs of exudate in bronchial branches, down to terminal bronchioles Hypertrophy of bronchial smooth muscle Hyperplasia of mucosal & submucosal blood vessels Mucosal oedema Thickening of basement membrane Eosinophilic infiltrates in the bronchial walls
  • 9. History and patterns of symptoms Physical examination Measurements of lung function Measurements of allergic status to identify risk factors
  • 10. Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds go to the chest or take more than 10 days to clear
  • 11. Lung function tests- FEV1/FVC ratio (15% improvement in FEV1) CXR Sputum (thick, with eosinophils + Charcots- Leyden crystals), blood (IgE levels, eosinophilia) Allergy tests- skin, inhalants, catecholamines etc.
  • 12. Asthma COPDcannot be fully prevented can be prevented can be fully controlled cannot be fully reversed does not progress is progressive
  • 13. COPD and Asthma are different diseases! Asthma COPD Allergic Small airway inflammation of COPD narrowing airways & & Asthma Bronchospasm Hyper- (15%) & responsiveness Airway collapse Bronchospasm Maintain Control inflammation bronchodilatation with ICS with regularMinimal bronchodilator bronchodilator
  • 14. History COPD AsthmaSmoker or ex- Nearly always VariablesmokerOnset Usually > 40 Most < 30 years yearsBreathlessness Gradual and Paroxysmal progressiveChronic cough Common Infrequentwith sputum
  • 15. Investigation COPD AsthmasFEV1 Always reduced VariableDaily variation in Minimal Morning dipPEF + day-to-dayReversibility 15%
  • 16. To effectively controll asthma byA. Suppressing and reversing inflammationB. Treating bronchoconstriction and related symptoms
  • 17. Life-threatening medical emergencies Treatment is often most safely undertaken in a hospital or hospital-based emergency department
  • 18. Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if neededGood Response Incomplete/Poor Response Respiratory FailureObserve for at Add Systemic Glucocorticosteroids least 1 hour Good Response Poor Response If Stable, Discharge to Discharge Admit to Hospital Admit to ICU Home
  • 19. Goals of Long-term Management Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation Prevent asthma mortality
  • 20. Uncontrolled Controlled (mild Partly controlled (moderate- Characteristic intermittent) (mild persistent) severe (All of the following) (Any present in any week) persistent) None (2 or less / More thanDaytime symptoms week) twice / week Limitations of 3 or more None Any features of activities partly Nocturnal controlled symptoms / None Any asthma awakening present in Need for rescue / None (2 or less / More than any weekreliever treatment week) twice / week < 80% predicted or Lung function Normal personal best (if (PEF or FEV1) known) on any day Exacerbation None One or more / year 1 in any week
  • 21. Preventers - anti-inflammatory Relievers - short acting bronchodilators that provide rapid relief of symptoms Controllers - sustained bronchodilator action with unproven or mild anti-inflammatory action
  • 22. Classification of drugs used in the maintenance treatment of asthma PREVENTERS CONTROLLERS RELIEVERS Anti-inflammatory Sustained broncho- For quick relief of action to prevent dilator action but weak symptoms and use in asthma attacks or unproven anti- acute attacks as p.r.n. inflammatory effect dose onlyInhaled Long-acting 2 Short-acting 2corticosteroids agonists agonists Beclomethasone Salmeterol Salbutamol Budesonide Formoterol Fenoterol Fluticasone Methylxanthines Terbutaline Flunisolide Hexoprenaline Triamcinolone Sustained-release Orciprenaline theophyllinesOral Anti-cholinergicscorticosteroids Leukotriene IpratropiumPrednisone receptor Short-actingPrednisolone antagonists** theophyllinesMethylprednisolone Montelukast Zafirlukast ** Provisional cate