Bronchial asthmaBronchial asthma

IntroductionIntroduction

Asthma is a common medical problem and its Asthma is a common medical problem and its prevalence is increasingprevalence is increasing

The morbidity and mortality is significant if The morbidity and mortality is significant if not treated adequatelynot treated adequately

AA chronic inflammatory disease of the airways chronic inflammatory disease of the airwayscharacterized by oedema, infiltration with characterized by oedema, infiltration with

inflammatory cells especially eosinophils, inflammatory cells especially eosinophils, hypertrophy of glands and smooth muscle and hypertrophy of glands and smooth muscle and damaged epithelium.damaged epithelium.

HyperresponsivenessHyperresponsivenessairways narrow easily in response to a wide airways narrow easily in response to a wide

range of stimuli.range of stimuli.

DefinitionDefinition

Wheezing, SOB, chest tightness and coughing Wheezing, SOB, chest tightness and coughing particularly in the night or in early morningparticularly in the night or in early morning

EpidemiologyEpidemiology

An estimated 4-5% of the population is An estimated 4-5% of the population is affected around the worldaffected around the world

AAll ages but predominant in early life.ll ages but predominant in early life.About 50% of cases develop before age of 10 About 50% of cases develop before age of 10

and another 30% occur before age of 40.and another 30% occur before age of 40.In childhood,there is 2:1 male/female In childhood,there is 2:1 male/female

preponderance, but the ratio equalizes by age preponderance, but the ratio equalizes by age 30 30

Triggering stimuli Triggering stimuli Allergens ( house dust mites, domestic pets, pollen)Allergens ( house dust mites, domestic pets, pollen) Aerosol chemicalAerosol chemical Atmospheric pollution. Atmospheric pollution. Changes in temperatureChanges in temperature Drugs( Aspirin, beta blockers)Drugs( Aspirin, beta blockers) ExerciseExercise Respiratory infectionRespiratory infection Emotional stress Emotional stress SmokeSmoke

PathophysiologyPathophysiology

Chronic inflamed airways become obstructed Chronic inflamed airways become obstructed and airflow is limited and airflow is limited

Bronchoconstriction, mucous plugs and Bronchoconstriction, mucous plugs and increase inflammation when expose to risk increase inflammation when expose to risk factorsfactors

Clinical featuresClinical features

Wheezing Wheezing H/o –cough worse particularly at nightH/o –cough worse particularly at night

- Recurrent wheeze, diff breathing and - Recurrent wheeze, diff breathing and chest tightness chest tightness

Sx worsen at night awakening pt/ seasonal Sx worsen at night awakening pt/ seasonal pattern or + risk factorpattern or + risk factor

Eczema, hay fever, F/H of asthma or diseaseEczema, hay fever, F/H of asthma or diseaseResponds to anti asthma therapyResponds to anti asthma therapy

A typical asthma patient..A typical asthma patient..

Tachypnea,Tachypnea, tacchycardia and mild systolic tacchycardia and mild systolic hypertension.hypertension.

Expiration is prolongedExpiration is prolonged

Typical symptoms…Typical symptoms… At the end of the episode cough becomes productive At the end of the episode cough becomes productive

of thickof thick ,stringy mucus,,stringy mucus, which often takes the form of which often takes the form of casts of the distal airways (Cruschmann’s spirals).casts of the distal airways (Cruschmann’s spirals).

Differential diagnosisDifferential diagnosis

Upper airway obstruction by tumour or Upper airway obstruction by tumour or laryngeal edemalaryngeal edema

Acute left ventricular failureAcute left ventricular failureCarcinoid tumoursCarcinoid tumoursRecurrant pulmonary embolismRecurrant pulmonary embolismChronic bronchitisChronic bronchitisEosinophilic pneumonias.Eosinophilic pneumonias.

DiagnosisDiagnosis

Demonstration of reversible airway diseaseDemonstration of reversible airway disease Greater than 15% increase of FEVGreater than 15% increase of FEV after two puffs of after two puffs of

β-adrenergic agonist.β-adrenergic agonist. Demonstration of hightened airway responsiveness to Demonstration of hightened airway responsiveness to

challenges with histamine,challenges with histamine, methacholine or methacholine or hyperventilation of cold airhyperventilation of cold air

PEFR’s to measure response to therapyPEFR’s to measure response to therapy Sputum examination for charcot-Layden crystals and Sputum examination for charcot-Layden crystals and

eosinophiliaeosinophilia Blood eosinophiliaBlood eosinophilia

Diagnosis…Diagnosis…

Chest X ray- Non specificChest X ray- Non specific,hyperinflated lungs,hyperinflated lungs Measurement of serum IgE levelsMeasurement of serum IgE levels Positive wheal-flare reaction to skin testsPositive wheal-flare reaction to skin tests ABG: Hypoxia, hypocapnia and respiratory alkalosis ABG: Hypoxia, hypocapnia and respiratory alkalosis

Management of Bronchial asthmaManagement of Bronchial asthma

Objectives:Objectives: Daytime symptoms- nil to thrice a weekDaytime symptoms- nil to thrice a week Night symptoms-nilNight symptoms-nil Normal lifestyle and physical activityNormal lifestyle and physical activity Exacerbations-nil to mildExacerbations-nil to mild Need for beta-2-agonist-nil to thrice a weekNeed for beta-2-agonist-nil to thrice a week FEV1,PEF-normal to > 90% of personal best.FEV1,PEF-normal to > 90% of personal best.

TreatmentTreatment

Treatment of asthma depends on severity of Treatment of asthma depends on severity of symptoms and patients are classified for this purpose symptoms and patients are classified for this purpose as as

1)Mild intermittant1)Mild intermittant 2)Mild persistant2)Mild persistant 3)Moderate persistant3)Moderate persistant 4)Severe persistant4)Severe persistant

Table 3. GINA classification of asthma severity by clinical Table 3. GINA classification of asthma severity by clinical features before treatmentfeatures before treatment

Symptoms/Day Symptoms/Day Symptoms/Symptoms/

Night Night

PEF or FEV1 PEF or FEV1 PEF variability PEF variability

STEP 1STEP 1 Intermittent Intermittent

< 1 < 1 xx a week a week

Asymptomatic Asymptomatic and normal PEF and normal PEF between attacks between attacks

≤ ≤ 2 2 xx a month a month ≥ ≥ 80% 80% < 20% < 20%

STEP 2STEP 2Mild Persistent Mild Persistent

1 time a week 1 time a week but < 1 time a but < 1 time a dayday Attacks may Attacks may affect activity affect activity

2 times a month ≥ 80% 20-30%

STEP 3STEP 3 ModerateModeratePersistent Persistent

Daily Attacks affect activity

> 1 time a week 60%-80% > 30%

STEP 4STEP 4 Severe Persistent Severe Persistent

Continuous Limited physical activity

frequentfrequent ≤ 60% > 30%

Drug treatment

1.Bronchodilators1.Bronchodilatorstreat symptoms of asthma. treat symptoms of asthma.

used as required rather than regularly. used as required rather than regularly.

asthma is severe and difficult to control, taken on regular asthma is severe and difficult to control, taken on regular basis. 3 main groups of bronchodilators:basis. 3 main groups of bronchodilators: Beta2 agonists Beta2 agonists Anticholinergics Anticholinergics MethylxanthinesMethylxanthines

a. Beta2 agonistsa. Beta2 agonists most effective most effective safe drugs with few side effects when taken by inhalationsafe drugs with few side effects when taken by inhalation side effects are tremors and tachycardiaside effects are tremors and tachycardia Oral slow release preparations and inhaled long acting beta2 Oral slow release preparations and inhaled long acting beta2

agonists such as Salmeterol /bambuterol are useful for agonists such as Salmeterol /bambuterol are useful for nocturnal asthma.nocturnal asthma.

Inhaled beta2 agonist:Inhaled beta2 agonist:

salbutamol (Ventolin, Respolin)salbutamol (Ventolin, Respolin)terbutaline (Bricanyl)terbutaline (Bricanyl)fenoterol (Berotec) fenoterol (Berotec) salmeterol (Serevent) - long actingsalmeterol (Serevent) - long acting

Oral long acting beta2 agonist:Oral long acting beta2 agonist:

salbutamol (Volmax)salbutamol (Volmax)terbutaline (Bricanyl durules)terbutaline (Bricanyl durules)bambuterol (Bambec)bambuterol (Bambec)

Oral short acting beta2 agonist:Oral short acting beta2 agonist:

salbutamolsalbutamolterbutalineterbutaline

b. Anticholinergic drugsb. Anticholinergic drugsRoute: Inhalation -lower onset asthmaRoute: Inhalation -lower onset asthma

longer duration of action. longer duration of action.

very few side effects.very few side effects.Examples: Ipratropium bromide (Atrovent) Examples: Ipratropium bromide (Atrovent)

c. Methylxanthines oral and parenteraloral and parenteral Sustained release preparations may be useful in nocturnal Sustained release preparations may be useful in nocturnal

asthma.asthma.

Examples: Nuelin SR, Theodur, Euphylline Examples: Nuelin SR, Theodur, Euphylline Note: Inhaled beta2 agonists are the bronchodilator of choice. Note: Inhaled beta2 agonists are the bronchodilator of choice.

2. Anti-Inflammatory Drug

A. Corticosteroids main prophylactic drugs. Route:Inhalation dosage should be kept to a minimum to reduce side effects

(usually local side effects). Oral steroids maybe required for severe chronic asthma.

Examples: Beclomethasone dipropionate

Budesonide (Pulmicort)

B. Sodium cromoglycate (Intal) very safe with no significant side effects. very safe with no significant side effects. Route: inhalation (power Spinhaler or metered dose inhaler). Route: inhalation (power Spinhaler or metered dose inhaler).

It is of greatest benefit in young, atopic patients.It is of greatest benefit in young, atopic patients.

Other treatmentsOther treatments Anti-histamines :ketotifen proven to be of limited efficacy in Anti-histamines :ketotifen proven to be of limited efficacy in

many clinical trials in asthmamany clinical trials in asthma

TreatmentTreatment

STEP 1 MANAGEMENTSTEP 1 MANAGEMENT:: No need for any long term daily medicationNo need for any long term daily medication Use short acting inhaled beta-2 agonist for quick Use short acting inhaled beta-2 agonist for quick

relief as necessary.relief as necessary. Teach about basic facts of asthma and inhaler Teach about basic facts of asthma and inhaler

technique and the role of medicationstechnique and the role of medications

STEP 2 MANAGEMENTSTEP 2 MANAGEMENT Step 1 +Low dose inhaled steroid.Step 1 +Low dose inhaled steroid. e.g. beclomethasone or budesonide 2puff BD or e.g. beclomethasone or budesonide 2puff BD or

sodium chromoglycatesodium chromoglycate For quick relief use a short acting inhaled bets-2-For quick relief use a short acting inhaled bets-2-

agonist as necessaryagonist as necessary Teach self monitoring of asthmaTeach self monitoring of asthma

STEP 3 MANAGEMENTSTEP 3 MANAGEMENT Daily long term control medicationsDaily long term control medications either medium or low dose inhaled steroid + long either medium or low dose inhaled steroid + long

acting beta-2-agonist / tablet / sustained acting beta-2-agonist / tablet / sustained T.theophyllineT.theophylline

For quick relief inhaled short acting beta–2- agonist For quick relief inhaled short acting beta–2- agonist as often as necessaryas often as necessary

Educate about step 1 and step 2 actionsEducate about step 1 and step 2 actions

Step 4 managementStep 4 management Step 3+oral corticosteroidsStep 3+oral corticosteroids Quick relief medications :SalbutamolQuick relief medications :Salbutamol

STEP UP and STEP DOWNSTEP UP and STEP DOWN

Step up: asthma control is not maintained, going up Step up: asthma control is not maintained, going up to to the next treatment level after reviewing the next treatment level after reviewing medication technique, adherence and medication technique, adherence and

environmental control environmental control Step down: reviewing symptoms every 1-6 months Step down: reviewing symptoms every 1-6 months

and a gradual step-wise reduction in and a gradual step-wise reduction in treatment may be possible treatment may be possible

Management Of Chronic Asthma In Adults Management Of Chronic Asthma In Adults

30-60 mg of prednisolone immediately30-60 mg of prednisolone immediately tapered down and stopped within 7-14 days. tapered down and stopped within 7-14 days.

Indications : Indications : symptoms and peak expiratory flow (PEF) get progressively worse symptoms and peak expiratory flow (PEF) get progressively worse

day by day. day by day. PEF <60%PEF <60% Sleep disturbedSleep disturbed morning symptoms persist until midday. morning symptoms persist until midday. diminishing response to inhaled bronchodilators. diminishing response to inhaled bronchodilators. required emergency Rx with neb or injected bronchodilatorsrequired emergency Rx with neb or injected bronchodilators

Assessment of severity of asthmaAssessment of severity of asthma

History taking History taking Physical examination Physical examination PEF measurement PEF measurement

Features of moderately severe asthma Features of moderately severe asthma normal speech normal speech pulse rate < 110/min pulse rate < 110/min respiratory rate < 25 breaths/min respiratory rate < 25 breaths/min PEF > 50% predicted or best value PEF > 50% predicted or best value

Features of acute severe asthma Features of acute severe asthma too breathless to complete sentences in one breath too breathless to complete sentences in one breath respiratory rate ³ 25 breaths/min respiratory rate ³ 25 breaths/min pulse rate ³ 110/min pulse rate ³ 110/min PEF £ 50% predicted or best value PEF £ 50% predicted or best value

Life threatening features: Life threatening features: central cyanosis central cyanosis feeble respiratory effort feeble respiratory effort silent chest on auscultation silent chest on auscultation bradycardia or hypotension bradycardia or hypotension exhaustion exhaustion confusion or unconsciousness confusion or unconsciousness PEF < 33% predicted or best value /(<150 l/min of PEF < 33% predicted or best value /(<150 l/min of

patients who are not able to blow) patients who are not able to blow)

ABG (normal or high PaCO2 )ABG (normal or high PaCO2 ) severe hypoxaemia: PaO2 < 60 mmHg irrespective of severe hypoxaemia: PaO2 < 60 mmHg irrespective of

treatment with oxygen treatment with oxygen a low pH a low pH

Management Of Acute Asthma Management Of Acute Asthma

1. PEF > 75% (Mild acute asthma) :1. PEF > 75% (Mild acute asthma) : inhaled bronchodilator (e.g. salbutamol, terbutaline or inhaled bronchodilator (e.g. salbutamol, terbutaline or

fenoterol) from MDIfenoterol) from MDI Observe for 60 minutesObserve for 60 minutes stable and PEF still >75%stable and PEF still >75% discharge. discharge.

2. Initial PEF < 75% 2. Initial PEF < 75%

A. ImmediateA. Immediate high concentration oxygen (>40%) in cases with high concentration oxygen (>40%) in cases with

initial PEF <50%initial PEF <50% salbutamol 5mg or terbutaline 5mg or fenoterol 5mg salbutamol 5mg or terbutaline 5mg or fenoterol 5mg

via nebuliser driven by oxygen.via nebuliser driven by oxygen.

*Salbutamol 2-5mg, i.e. 20-50 puffs, 5 puffs at a time *Salbutamol 2-5mg, i.e. 20-50 puffs, 5 puffs at a time via pressurised aerosol inhaler into a large spacer via pressurised aerosol inhaler into a large spacer devicedevice

*Add ipratropium bromide 0.5mg to nebulised beta2 *Add ipratropium bromide 0.5mg to nebulised beta2 agonist for patients with acute severe asthma.agonist for patients with acute severe asthma.

T. Prednisolone 30-60mg OD T. Prednisolone 30-60mg OD Very ill patients should be given IV hydrocortisone Very ill patients should be given IV hydrocortisone

200mg stat.200mg stat.

Sedatives should not be prescribed. Sedatives should not be prescribed. AntibioticsAntibioticschest x-ray if pneumothorax or pneumonia or chest x-ray if pneumothorax or pneumonia or

features of acute severe or life threatening asthmafeatures of acute severe or life threatening asthma

B. Life threatening features are present:B. Life threatening features are present: IV aminophylline 250mg slowly over 20 minutes IV aminophylline 250mg slowly over 20 minutes or IV terbutaline or salbutamol 250mcg over 10 or IV terbutaline or salbutamol 250mcg over 10

minutes.minutes. Bolus aminophylline should not be given to patients Bolus aminophylline should not be given to patients

already taking oral theophylline.already taking oral theophylline.

3. Subsequent Management In The Ward Or ICU3. Subsequent Management In The Ward Or ICU Continue – O2 at 40% Continue – O2 at 40% IV hydrocortisone 200mg 6-hourly or T.prednisolone IV hydrocortisone 200mg 6-hourly or T.prednisolone

30-60mg OD 30-60mg OD neb beta2-agonist 4-hourly or up to every 15-30 minneb beta2-agonist 4-hourly or up to every 15-30 min add ipratropium bromide 0.5mg to neb beta2-agonist add ipratropium bromide 0.5mg to neb beta2-agonist

and repeat 6-hourly if patient not improving.and repeat 6-hourly if patient not improving.

still not improvingstill not improving aminophylline infusion (0.5-0.9mg/kg/hour); monitor aminophylline infusion (0.5-0.9mg/kg/hour); monitor

blood levels (where facility is available) if continued blood levels (where facility is available) if continued for more than 24 hours. for more than 24 hours.

*terbutaline or salbutamol infusion 3-20mcg/min *terbutaline or salbutamol infusion 3-20mcg/min after an initial IV bolus dose of 250mcg over 10 min.after an initial IV bolus dose of 250mcg over 10 min.

MonitoringMonitoring Repeat PEF 15-30 min after starting treatment. Repeat PEF 15-30 min after starting treatment. Maintain ABG SPo2 > 92%Maintain ABG SPo2 > 92%

During acute exarcerbation..During acute exarcerbation..

Neb Combivent/ AVN 2:2:2 STAT then 4hrlyNeb Combivent/ AVN 2:2:2 STAT then 4hrly Oxygen NP 3L/minOxygen NP 3L/min IV hydrocortisone 200mg STAT then 100mg QIDIV hydrocortisone 200mg STAT then 100mg QID Oral Prednisolone 30mg OD for 5/7Oral Prednisolone 30mg OD for 5/7 T.neulin SR 250mg BDT.neulin SR 250mg BD Syp Benadryl 15ml tdsSyp Benadryl 15ml tds T.Bisolvan 8mg tdsT.Bisolvan 8mg tds T.EES 800mg BDT.EES 800mg BD T.Augmentin 625mg BDT.Augmentin 625mg BD

Pre and Post Neb PEFRPre and Post Neb PEFR MDI Salbutamol 2Puff PRNMDI Salbutamol 2Puff PRN MDI Beclomethasone 2Puff BDMDI Beclomethasone 2Puff BD Refer Phamarcist for MDI techniqueRefer Phamarcist for MDI technique

Severe asthma attack

ABGABG IV MgSO4 2g in 20cc NS/30minsIV MgSO4 2g in 20cc NS/30mins IV Salbutamol 5mg in 500cc NS and infusion 3ml/hrIV Salbutamol 5mg in 500cc NS and infusion 3ml/hr KIV intubationKIV intubation

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