BRONCHIAL ASTHMA IN ADULT

Zulkarnain Arsyad

Pulmonary Sub. Division of Internal Medicine Medical Faculty Andalas University M.Djamil Hospital Padang

What is Asthma?Chronic inflammatory disorder of airwaysInflammation causes airway hyper - responsiveness often associated with symptoms (wheeze, cough, SOB). Obstruction is reversible

Introduction In the community prevalence of bronchial asthma approximately are 4 6 %

Prevalence of asthma appears to be increasing in the children than adult

In the population, male asthmatic patients approximately are same with the female asthmatic patients

The are various factors, such as the environment, socio economic status, climate and ethnic group have the role in the prevalent of asthma

INFLAMMATIONPathogenesis:

Pathogenesis - Atopic Asthma:

Mast cells in Asthma Pathogenesis:

Eosinophils in Asthma Pathogenesis:

Asthma - Bronchial morphologyinflammation EosinophilsGland hyperplasiaMucous plug in lumenHypertrophy of muscle layer

Pathophysiology of asthmaVariety of stimuly

chronic a.w inflamation/ HBR

Acute reversible a.w obstInflamatory component early respont late respont

Patophysiology of asthmaAirway inflamation

Reversible a.w obstrc, Hallmarks : - Smooth msc contrct - Oedem - Mucous hyper secretionMast cell histamin release etc, broncho constriction

What is the Pathophysiology of Asthma?Pathological changes found in asthma are the 3 Ss:

1. Spasm of smooth muscle hypertrophy which contracts during an attack2. Swelling or oedema of bronchial mucosa3. Secretions from hypertrophy of mucus glands leading to thick & tenacious mucus

All the above cause bronchial narrowing

Pathophysiology of AsthmaIf left untreated chronic airway inflammation may lead to permanent airway changesAirway thickening causes irreversible airflow limitation and shortened life expectancy

Common Asthma TriggersURI Allergens Aerobic ExerciseIrritantsAir PollutionStrong emotionsMedicationsBeta blockers

Clinical PresentationWheezingDyspneaChest tightnessUse of accessory respiratory muscleCentral or peripheral cyanosisTachycardiaProlonged expirationAltered mental status

Classification of SeverityCLASSIFY SEVERITYClinical Features Before TreatmentSymptomsNocturnalSymptomsFEV1 or PEFSTEP 4Severe PersistentSTEP 3Moderate PersistentSTEP 2Mild PersistentSTEP 1IntermittentContinuousLimited physical activityDailyAttacks affect activity> 1 time a week but < 1 time a day< 1 time a weekAsymptomatic and normal PEF between attacksFrequent> 1 time week> 2 times a month 2 times a month 60% predictedVariability > 30%60 - 80% predicted Variability > 30% 80% predictedVariability 20 - 30% 80% predictedVariability < 20%The presence of one feature of severity is sufficient to place patient in that category.

What is an Asthma Exacerbation?Episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness, or some combination of these symptoms.2

2. Global Strategy for Asthma Management and Preventionwww.ginaasthma.org

Cont What is an Asthma Exacerbation?Represent an exaggerated lower airway response to an environmental stimulus.

Respiratory viral infection - main trigger of severe exacerbations of asthma.

Airway inflammation is a key pathogenic feature

Which aspects of asthmatics history are important to current exacerbation?

Other Qs3Prior hospitilizationsICU admissionsRecent ED visitsCurrent medsCo-morbid conditions

3. Emergency Medicine Secrets 4th Edition

GOALS OF TREATMENTMaintain adequate oxygenationRelieve airflow obstructionReduce airway inflammationPrevent future relapses- Elimination of causative agents from the environment of an asthmatic individual

THERAPYQUICK-RELIEF MEDICATIONS (RELIEVER)

LONG-TERM CONTROL MEDICATIONS (CONTROLLER)

Stepwise Approach to Asthma Therapy: Adults Step 1: Intermittent Asthma None requiredRapid-acting inhaled 2-agonistfor symptoms (but < 3-4times/day) Rapid-acting inhaled 2-agonist,cromone, or leukotriene modifier before exercise or exposure toallergenContinuously review medication technique, compliance and environmental controlReview treatment every three months.Step up if control is not achieved; step down if control is sustained for at least 3 monthsPreferred treatments are in bold print

Daily Controller MedicationsReliever Medications

Inhaled glucocorticosteroid (< 500 g BDP or equivalent)

Other options (order by cost):sustained-release theophylline, orCromone, or leukotriene modifierRapid-acting inhaled 2-agonistfor symptoms (but < 3-4 times/day)

Other options: inhaled anticholinergic, orshort-acting oral 2-agonist, orshort-acting theophylline

Continuously review medication technique, compliance and environmental control.Review treatment every three monthsStep up if control is not achieved; Step down if control is sustained for at least 3 monthsPreferred treatments are in bold print

Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent AsthmaDaily Controller MedicationsReliever Medications

Inhaled glucocorticosteroid, (200 1000 g BDP or equivalent) plus long-acting inhaled 2agonistOther options (order by cost):Inhaled glucocorticosteroid (500 1000 g BDP equivalent) plus sustained-release theophylline, orInhaled glucocorticosteroid (500 1000 g BDP equivalent) plus long-acting inhaled 2- agonist, orinhaled glucocorticosteroid at higher doses (> 1000 g BDP equivalent), orInhaled glucocorticosteroid (500 1000 g BDP equivalent) plus leukotriene modifier

Rapid-acting inhaled 2-agonist for symptoms (but < 3 - 4 times/day)

Other options: inhaled anticholinergic orshort-acting oral 2-agonist orshort-acting theophylline Continuously review medication technique, compliance and environmental control.Review treatment every three months.Step up if control is not achieved; Step down if control is sustained for at least 3 months.Preferred treatments are in bold print.Stepwise Approach to Asthma Therapy: AdultsStep 3: Moderate Persistent AsthmaDaily Controller MedicationsReliever Medications

Inhaled glucocorticosteroid, (> 1000 gBDP or equivalent) plus long-actinginhaled 2agonist

plus one or more of the following, ifneeded (order by cost):sustained-release theophylline, orleukotriene modifier ororal glucocorticosteroidRapid-acting inhaled 2-agonist for symptoms (but < 3-4 times/day)

Other options: inhaled anticholinergic orshort-acting oral 2-agonist orshort-acting theophyllineContinuously review medication technique, compliance and environmental control.Review treatment every three months.Step up if control is not achieved; Step down if control is sustained for at least 3 months.Preferred treatments are in bold print.Stepwise Approach to Asthma Therapy: AdultsStep 4: Severe Persistent AsthmaDaily Controller MedicationsReliever Medications

Part 4: Long-term Asthma ManagementStepwise Approach to Asthma Therapy - AdultsReliever:Rapid-acting inhaled 2-agonist prnController:Daily inhaledcorticosteroid Controller:Daily inhaled corticosteroid Daily long-acting inhaled 2-agonistController:Daily inhaled corticosteroid Daily long acting inhaled 2-agonistplus (if needed)

When asthma is controlled, reduce therapy

MonitorSTEP 1:IntermittentSTEP 2:Mild PersistentSTEP 3: Moderate PersistentSTEP 4:Severe PersistentSTEP DownOutcome: Asthma ControlOutcome: Best Possible ResultsAlternative controller and reliever medications may be consideredController:None -Theophylline-SR -Leukotriene -Long-acting inhaled 2- agonist -Oral corticosteroid

Principles of treatmentUse quick-relief rescue medication for all ptPersistent asthma requires : Long-term-control medication anti-inflammatory meds preferredStep up treatment if control not maintainedStep down if in control

Management of Asthma Exacerbations:Key PointsEarly treatment is best. Important elements include:A written action planGuides patient self-management of exacerbations at homeEspecially important for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbationsRecognition of early signs of worsening asthma

Management of Asthma Exacerbations:Key Points (continued)Appropriate intensification of therapyPrompt communication between patient and clinician about:Serious deterioration in symptoms or peak flow, orDecreased responsiveness to inhaled beta2-agonists, orDecreased duration of beta2-agonist effect

Management of Asthma ExacerbationsInhaled beta2-agonist to provide prompt relief of airflow obstructionSystemic corticosteroids to suppress and reverse airway inflammationFor moderate-to-severe exacerbations, orFor patients who fail to respond promptly and completely to an inhaled beta2-agonist

Management of Asthma Exacerbations (continued)Oxygen to relieve hypoxemia for moderate-to-severe exacerbationsMonitoring response to therapy with serial measurements of lung function

Risk Factors for Death From AsthmaPast history of sudden severe exacerbationsPrior intubation or admission to ICU for asthmaTwo or more hospitalizations for asthma in the past yearThree or more ED visits for asthma in the past year

Risk Factors for Death From Asthma (continued)Hospitalization or an ED visit for asthma in the past monthUse of >2 canisters per month of inhaled short-acting beta2-agonistCurrent use of systemic corticosteroids or recent withdrawal from systemic corticosteroids

Risk Factors for Death From Asthma (continued)Difficulty perceiving airflow obstruction or its severityComorbidity, as from cardiovascular diseases or chronic obstructive pulmonary diseaseSerious psychiatric disease or psychosocial problems

** Inflammation of the airways not only causes symptoms associated with widespread but variable airflow obstruction, it also results in an increase in airway hyperresponsiveness to a variety of stimuli (triggers) Environmental and genetic influences in asthma (inducers) act mainly by provoking airway inflammation, rather than directly stimulating airway hyperresponsiveness Triggers of bronchoconstriction, which are factors that provoke contraction of the sensitised airway wall, include a wide range of stimuli, such as exercise, cold air and pollen Allergens can act as both inducers and triggers**************1234567