Prof. Sevda Özdoğan MD, Chest Diseases
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Transcript of Prof. Sevda Özdoğan MD, Chest Diseases
Prof. Sevda zdoan MD, Chest Diseases
Asthma Prof. Sevda zdoan MD, Chest Diseases DEFINITION Asthma is a
chronic inflammatory disorder of the airways that causes a
bronchial hyperreactivity which leads to recurrent episodes of
reversible airflow obstruction with wheesing, breathlesssness,
chest tightness and coughing Characteristics of the disease:
Chronic inflammation BHR Diffuse reversibl airway obstruction
Bronchial hyperreactivity Airway wall remodeling
Genetic predisposition: Multiple genes, Risk in a child is 20-30%
if one parent has asthma; 70% if both the parents have asthma +
Environmental factors: High allergen exposure (dust mite, cat, dog,
fungi etc); Passive smoking; Respiratory infections; air
pollution;occupational exposure INFLAMATION Bronchial
hyperreactivity Airway wall remodeling Airflow limitation Symptoms
Clinical signs and symptoms
Asthma can be diagnosed on the basis of symptoms Episodic
breathlessness Wheesing Chest tightness Cough (sometimes thick
sputum) Seasonal variability of symptoms Family history of asthma
or atopic disease Physical examination Normal (Does not exclude
asthma!!)
Wheesing on oscultation (Dyspnea, wheesing, hyperinflation are more
likely to be present during symptomatic periods) Wheesing can be
absent in severe asthma (silent chest) Cyanosis Drowsiness
Difficulty in speaking Tachicardia Hyperinflated chest Accesory
muscle activation with intercostal recession Diagnosis Measurements
of lung function (PFT)
Spirometry (FEV1/FVC200ml art olmas Ge reversibilite 2-6 haftalk
inhale veya sistemik steroid tedavisi sonras tekrarlanan FEV1 ve
FVC de %15, PEF de %20 lik art olmas Chest x-ray (important in
differential diagnosis)
Sputum or nasal smear eosinophyls Measurement of allergic status
Skin testing Specific Ig E in serum (A positive test does not mean
allergic asthma so must be confirmed by history of exposure and
attack) Factors that precipitate asthma exacerbations
(Triggers)
Allergens (indoor and outdoor) Respiratory infections (RSV,
Influensa) Exercise and hyperventilation Cold air, weather changes
Foods, additives and drugs Irritant gases (air polution, smoking)
Extreme emotional expression Occupational agents Gastroesophageal
reflux Chronic rhinosinusitis Smoking passive or active Allergens
Drugs or agents associated with induction of bronchospasm
Acetylsalicylic acid NSAI Beta blockers Contrast agents Cocaine
Heroin Dipyridamol Hydrocortisone Beclomethasone inh Pentamidine
inh Protamine Vinblastine Mitomycin IL-2 Different Diagnostic
Groups
Asthma in Elderly (differentiation from cardiac asthma, drug
effects, changes in the perception of symptoms, difficulty in
performing PFT, false positive reversibility) Occupational Asthma
Cough variant asthma Exercise induced asthma Samter syndrome Asthma
in pregnancy The younger the child, the greater the likelihood that
an alternative diagnosis may explain recurrent wheese Samter
syndrome, astma, aspirin intolerance and nasal poliposis, sinusitis
Treatment Goals in Asthma
Prevent asthma attacks Achieve and maintain control of symptoms
Maintain pulmonary function as close to normal levels as possible
Maintain normal activity levels, including exercise (Increase life
quality) Avoid adverse effects of medication Prevent development of
irreversibl airflow limitation Prevent asthma mortality Treatment
program Educate patients to develop a partnership in asthma
management Assess and monitor asthma severity Avoid or control
asthma triggers Establish individual medication plans Establish
plans for managing exacerbations Provide regular follow-up care
Asthma medications Controllers:
Inhaled corticosteroids (systemic steroids) Long acting
bronchodilators (beta agonist) Methylxantines (Theophyline)
Leukotriene modifiers Chromones New drugs: Anti IgE (Omeluzimab)
Relievers: quick relief medicine or resque medicine
Short acting beta2 agonist Systemic corticosteroids Theophylline
Anticholinergics Corticosteroids The most effective antiinflamatory
medications
mproves lung function Decreases airway hyperreactivity Reduces
symptoms Reduces exacerbations mproves quality of life Side effects
of systemic (inhaled)steroids
Skin thinning (stria) Adrenal suppression Osteoporosis Arterial
hypertension Diabetes Cataracts Glaucoma Obesity Muscle weakness
Oropharyngeal candidiasis Dysphonia Occasionalcoughing Inhaled
forms Drug is delivered directly to the targed Quick effect
Small doses Negligable systemic absorbtion Less side effects LABA
Formeterol, Salmeterol Relax airway smooth muscle
Decrease vascular permeability Enhance mucosilier clearance
Modulate mediator release from mast cells and basophyls Activity
persists for 12 hours Combined Inh CS+LABA Side effects: Improves
symptom scores
Improves lung function Decreases exacerbations and resque medicine
use Side effects: Cardiovascular stimulation Skeletal muscle tremor
Hypokalemia Methylxantines (Theophylline)
Bronchodilator effect (8-12 mg/ml) related to phosphodiesterase
inhibition) Antiinflamatory effect (5-10 mg/ml) Used in add-on
therapy (Stimulation of respiratory center, diuretic) Side effects:
Nausea, vomiting Tachycardia, arrhytmia Seizures, death (>20
mg/ml) Leukotriene modifiers
Montelucast, Zafirlucast, Zileuton Inhibit the effects of cysteinyl
leucotriens released from mast cells and eosinophyls Used in add on
therapy to reduce the CS dose in moderate and severe asthma
Chromones Nedocromil sodium Sodium chromoglycate
Nonsteroidal anti-inflamatory drugs Inhibit IgE mediated mediator
release Less effective than corticosteroids Specific
Immunotherapy
Subcutaneus or sublingual administration of allergen extracts Very
limited indication Greatest benefit in patients with allergic
rhinitis that has been unresponsive to conventional pharmacotherapy
or specific environmental control Short acting beta agonists
Salbutamol, terbutaline Provide rapid relief of symptoms Duration
of action is 4-6 hours Anticholinergics Ipratropium bromide (short
acting)
Block the effect of acethylcoline released from cholinergic nerves
in the airways Less potent bronchodilators than beta agonists in
asthma Side effects: Dryness of mouth, bitter taste Glacoma Uretral
spasm Asthma out of control Check: Imcompliance to
treatment!!
Exposure to precipitating factor? Respiratory Infection? GERD?
Psychologic stress? End ekspiratory wheese Moderate Talking Few
words +
Breathlesness Speaking Agitation Accesory muscle activity Wheesing
Respir Rate Pulse Pulsus paradoksus PEF PaO2 PaCO2 SaO2 Oscultation
Mild attack Walking Sentences - Mild < 20 < 100 < 10 mmHg
> %80 Normal < 45 mmHg > %95 End ekspiratory wheese
Moderate Talking Few words + Severe 20-30 10-25 mmHg %60-80 > 60
mmHg < 45 mmHg %91-95 generalised (Full eksp) Severe Rest
(Ortopnea) Word + > 30 > 120 > 25 mmHg < %60 < 60
mmHg > 45 mmHg < %90 Expiratory and inspiratory Pulsus
paradoksus: atakta intraplevral negatif basncn artmasna bal
inspiryumda sistolik basncn ekspiryuma gre daha dk olmas Treatment
in mild attack
inhaled short acting beta2 agonist 4-8 puff every 20 min for the
first hour/ nebulization (2,5 mg) 1-2 times O2 optional If
incomplete improvement after the first hour repeat the protocole
Partial improvement: moderate attack treatment Moderate attack
treatment
Nasal O2 1-2 lt/min nhaled short acting beta2
agonist+anticholinergic 4-8 puf/20 min/hour then 2-4 puff/hour Oral
or IV prednisolon mg/kg (divided to 2-4 doses) Continue to
treatment 1-3 hours Severe attack treatment
4-6 lt/min nasal O2 5 mg salbutamol nebulisation/20 min or
continious nebulisation mg/kg (Anticholinergic) 0.5 mg ipratropium
bromide nebulisation IV prednisolon mg/kg No response after the
first 1-2 hours: Nasal O2 continued IV prednisolon repeated every 4
hours (Total mg/day) Salbutamol+ anticholinergic nebulisation
repeated every 4 hours IV Aminophyline 6mg/kg in min than mg/kg/hr
infusion v magnesium 2 gr/50 ml SF (30 min infsion) sc or v
adrenaline if necessary 8-10 hours follow up Unresponsive to
treatment, detoriation; Intensive care Incomplete remission:
Hospitalization (If PEF < %70) Fine response: Discharge (If PEF
> %70) ventolin bricanyl atrovent combivent Prednol amp Teobag
200mg/100 ml THANKS