Bronchial Asthma
Dr. Nooreldin Mohamed Elkosh PGY1 Family Medicine Residency
Program, Hamad Medical Corporation
DEFENITION
• Asthma is a common chronic inflammatory disease of the airways characterized by recurent and reversible episodes of airflow obstruction and bronchospasm.
• Common symptoms include wheezing, coughing, chest tightness, and shortness of breath.
EPIDEMIOLOGY
• As of 2004, it was estimated that as many as 300 million people of all ages suffer from asthma. By 2025, it is expected that this number will rise to 400 million worldwide.
• The rate of asthma increases as communities adopt western lifestyles .
• The increase in the prevalence of asthma has been associated with an increase in atopic sensitization and other allergic disorders such as eczema and rhinitis
• It is estimated that asthma accounts for about 1 in every 250 deaths worldwide. Many of these could be prevented with optimal access to medical care
• Asthma in the Gulf countries:Saudi Arabia took the lead, with a rate of 24%
of the population suffering. Qatar and Kuwait came next, with a rate of
19.8% and 16.8% respectively, followed by 13% in the United Arab Emirates
Oman had the lowest prevalence among the Gulf Cooperation
• Prevalence of asthma among Qatari schoolchildren aged 6-14 years according to International Study of Asthma and Allergies in Childhood, Qatar:
A cross-sectional study of 3,283 school children living in both urban and rural areas was conducted between February 2003-February 2004:
• The population sample had a high prevalence of diagnosed asthma (19.8%), allergic rhinitis (30.5%), eczema (22.5%), and chest infection (11.9%).
• The frequency of asthma, allergic rhinitis, and eczema among parents reflected the same pattern as seen in their children
• Overall, males had more asthma, allergic rhinitis, and chest infections than females
• In general, the prevalence rate of asthma and allergic rhinitis decreased with age
• Genetic factors related to the high rates of consanguinity may play an important role in the high prevalence rates noted in the Qatari population, but changes in lifestyle and environmental factors cannot be discounted as possible causes of the high prevalence noted in this study.
The Impact of Asthma and Allergic Diseases on Schoolchildren: Are they at Increased Risk of Absenteeism and Poor School Performance?Dept. of Epidemiology and Medical Statistics, Hamad Medical Corporation Dept. of Public Health, Weill Cornell Medical College State of Qatar
• Asthma is the most common chronic illness among school children and an important cause of school absenteeism and reduced participation in sports and other activities
• Asthma is the principal cause of school absences due to chronic disease in childhood accounting for 20% of school days lost among elementary and high school students
RISK FACTORS
• GENDER — There are clear-cut gender differences in the
prevalence of asthma. Childhood asthma tends to be a predominantly male disease, with the relative male predominance being maximal at puberty.
After age 20, the prevalence remains approximately equal until age 40, when the disease becomes more common in females.
• Airway hyperreactivity — Abnormal and exaggerated airway
responsiveness to noxious stimuli is a central feature in the pathophysiology of asthma, and all patients with asthma have airway hyperresponsiveness
• FAMILIAL HISTORY OF ASTHMA —
• ATOPY AND ALLERGENS — Atopy may be defined as the state of having IgE antibodies
to specific allergens, which is a prerequisite for developing allergic disease.
The association between asthma and other atopic conditions is well-documented.
The "atopic march" is a term used to describe the pattern of onset of different allergic diseases that is observed in some atopic individuals.
This pattern begins with atopic dermatitis in infancy and childhood, followed by the onset of allergic rhinitis and then asthma during later childhood and adolescence.
• Allergen exposure — Sources of indoor allergens include: house dust mites, animal proteins (particularly
cat and dog allergens), cockroaches, and fungi• RHINITIS — Adults with rhinitis are at greater risk than
those without rhinitis for developing adult-onset asthma
• OCCUPATIONAL EXPOSURES — The European Community Respiratory Health
Surveys (ECRHS and ECRHS-II) identified several occupations that are associated with an increased risk of new onset asthma; nursing and cleaning were responsible for the most cases .Inhalational accidents (eg, fires, mixing cleaning agents, industrial spills) were also associated with an increased risk of new onset asthma.
In the Agricultural Health Study of 25,814 adult farm women, growing up on a farm was protective against asthma, but use of certain pesticides (eg, organophosphates) was associated with an increased risk of adult-onset atopic asthma
• Outdoor pollution — There is a known correlation between levels of air pollution and lung disease, but the association between air pollution and asthma is less clear
• Indoor pollution— Gas stoves are the primary source of indoor NO2 which is responsible for increasing wheeze ,shortness of breath and chest tightness
• RESPIRATORY INFECTIONS —Viral and bacterial respiratory infections are
well-known triggers that can cause exacerbations in children and adults with asthma
There are no conclusive epidemiologic data linking infections to causation of asthma in previously normal adults
• SMOKING AND EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE —
1- Active smoking — Several studies have demonstrated that active smoking increases the risk for developing asthma
Secondhand smoke — There is a growing evidence that secondhand smoke exposure is associated with the development of asthma in early life
• Maternal smoking is the most important cause of secondhand smoke exposure, because of the greater exposure of the child to the mother than the father
• OBESITY — There is a linear relationship between BMI and
the risk of developing asthma• EARLY MENARCHE —asthma symptoms and bronchial hyperreactivity
are more common among adult women with menarche before the age of 11 years compared with menarche at age 13 or later based on a large multinational study
• MEDICATION USE — Epidemiologic studies have found associations
between the development of asthma and both the regular use of acetaminophen and exposure to antibiotics during infancy.
However, these studies have inadequately accounted for confounding bias. Both of these associations warrant further study.
• Asprin induced asthma (Samter's triad ):is a medical condition consisting of asthma,
aspirin and NSAID sensitivity, and nasal/ethmoidal polyposis.
• Mode of delivery — Delivery by Cesarean section may increase the
risk of childhood asthma compared with vaginal delivery
• Exercise, Cold exposure, Excessive laughing
PATHOGENESIS• 1- Allergic Asthma (Extrensic Asthma )• 2-Non allergic Asthma (Intrensic Astma )
EXTRENSIC ASTHMA
• Allergic (Extrinsic) Asthma : Bronchoconstriction Airway edemaAirway hyperresponsivenessAirway remodeling
• Non allergic (Intrinsic) Asthma: triggered by factors not related to allergies Many of the symptoms of allergic and non-allergic
asthma are the same (coughing, wheezing, shortness of breath or rapid breathing, and chest tightness), but non-allergic asthma is triggered by other factors such as anxiety, stress, exercise, cold air, dry air, hyperventilation, smoke, viruses or other irritants
the immune system is not involved in the reaction.
THANK YOU
Drugs used in Bronchial Asthma
Dr. Sherif Adel Saleh, PGY-1 Family Medicine Residency Program,
Hamad Medical Corporation
Pathophysiology of asthma
Classification• Bronchodilators
– β Sympathomimetics: Salbutamol, Terbutaline, Bambuterol, Salmeterol, Formoterol, Ephedrine.
– Methylxanthines: Theophylline (anhydrous), Aminophylline, Choline theophyllinate, Hydroxyethyl theophylline, Theophylline ethanolate of piperazine, Doxophylline.
– Anticholinergics (muscarnic receptor antagonist): Ipratropium bromide, Tiotropium bromide.
Classification
• Leukotriene antagonists: Montelukast, Zafirlukast.
• Mast cell stabilizers: Sodium cromoglycate, Ketotifen.
• Corticosteroids– Systemic: Hydrocortisone, Prednisolone and others.– Inhalational: Beclomethasone dipropionate, Budesonide, Fluticasone
propionate, Flunisolide, Ciclesonide.
• Anti-lgE antibody: Omalizumab
Bronchial Asthma: Treatment approaches• Prevention of antigen antibody reaction: Avoidance of antigen,
hyposensitization
• Neutralization of IgE: Omalizumab
• Suppression of inflammation and bronchial hyper reactivity: Cotricosteroids
• Prevention of release of mediators: Mast cell stabilizers
• Antagonism of released mediators: Leukotriene antagonists, antihistamines, platelet aggravating factor (PAF) antagonist
• Blockade of constrictor neurotransmitter: Sympathomimetics
• Directly acting bronchodilators: Methylxanthines
Bronchodilators
Stimulates
2-adrenergic
receptors of bronchi
2-agonists Anticholinergic drugs
Smooth muscle
relaxation
reduce tonus
of vagus
Methylxanthinesinhibit phosphodiesterase
2-agonists: treatment of acute asthmatic attacks
Muscarinic antagonist: Less useful in asthma, may be given in refractory cases
Methylxanthines: Long-term/ prevent bronchoconstriction
2-agonists: treatment of acute asthmatic attacks
Muscarinic antagonist: Less useful in asthma, may be given in refractory cases
Methylxanthines: Long-term/ prevent bronchoconstriction
Sympathomimetics
• The selective β2 agonist is the primary bronchodilators used in acute asthmatic attacks.
• β2 adrenergic receptor agonists increase the cAMP concentration in smooth muscles causing bronchodilatation.
• Types: – Long-acting β2 adrenergic receptor agonists (Salmeterol; formoterol)
– Short-acting β2 adrenergic receptor agonists (salbutamol, levalbuterol, metaproterenol, terbutaline, and pirbuterol )
Sympathomimetics• Salbutamol:
– Selective β2 agonists with less cardiac side effects
– Inhaled salbutamol produce bronchodililation within 5-min and the action lasts for 2-4 h.
– Used for acute asthmatic attack. Not suitable for prophylaxis– Side effect: Palpitation, restlessness, nervousness, throat irritation and ankle
edema.– Metabolism: metabolized in gut; oral bioavailability is 50%.– Duration of action: oral salbutamol acts 4-6 h.– Dose: 2-4 mg/ oral; 0.25- 0.5 mg/ i,.p., or s.c.,; 100-200 μg/ inhalation
• Terbutaline:– Similar to salbutamol; regular use dose not reduce bronchial hyper-reactivity– Dose: 5 mg/ oral; 0.25 mg/ i,.p., or s.c.,; 250 μg/ inhalation
Cont.,
Sympathomimetics• Bambuterol:
– prodrug of terbutaline– Slowly hydrolyzed in plasma and lung by pseudocholinesterase to release the
active drug over 24 h. It also reversely inhibits pseudocholinesterase in a dose dependent manner.
– Used in chronic bronchial asthma in a singe evening dose of 10-20 mg/ oral.
• Salmeterol:– First long acting selective β2 agonists with slow onset of action
– Twice daily for maintain the therapy/ nocturnal asthma, but not for acute asthma– Concurrent use of inhaled glucocorticoid with salmeterol is advised for patient
with persistent asthma. – COPD: equivalent to inhaled anticholinergics in COPD. Reduce breathlessness by
abolishing the reversible component of airway obstruction.
• Formoterol:– Long acting selective β2 agonists which acts 12 h when inhaled.
– Compare to salmeterol it has a faster onset of action (with in 10 min)
Cont.,
Methylxanthines• Caffeine (from coffee) , theophylline (from tea) and theobromine
(from cocoa) are naturally occurring xanthine alkaloids which have qualitatively similar actions.
• Mechanism of action:
– Methylxanthines inhibits cyclic nucleotide phosphodiesterase (PDEs), thereby lead to an accumulation of intracellular cAMP and cGMP causing bronchodilation.
Methylxanthines
• Mechanism of action:
BronchodilationBronchodilation
Bronchial tone
Muscarinic antagonistMuscarinic antagonist
AcetylcholineAdenosine
Theophylline
cAMP
ATP
AMP
Adenylyl cyclaseAdenylyl cyclase
Phosphodiesterase (PDE)Phosphodiesterase (PDE)TheophyllineTheophylline
Beta agonistBeta agonist
Pharmacological actions of Methyl xanthines
CNSStimulationIncrease motor activityImprove the performance
CVSStimulate the heartIncrease the force of contractionHigh dose: cardiac arrhythmiasBP: effect is variable Stimulation of Vegas stimulation: ↓ BP Vasomotor center : ↑ BP
Smooth muscle
RelaxationLungs vital capacity- increasedBiliary spasm: relieved
Kidney
Mild diuretics (Inhibiting reabsorption of Na+ & H2O)
Increase the renal blood flowIncrease the g.f.r.
Mast cellInhibit the release of histamine
StomachEnhance the secretion of acid, Pepsin
MetabolismIncrease BMR
It has variable physiological actions
Methylxanthines- Theophylline Cont.,
• Adverse effects:– Narrow margin safety, – Multiple drug interactions (Erythromycin, ciprofloxacin, cimetidine, oral
contraceptives, allopurinol, phenytoin, rifampicin, phenobarbital)– CVS and CNS stimulant; ADRs not dependent to dose; GIT distress– Children are more liable to developed CNS toxicity– Rapid IV injection cause- precordial pain, syncope and sudden death
AnticholinergicsIpratropium (derivative of atropine)
• Parasympathetic activation causes bronchoconstriction and increases mucus secretion.
• Blocking the action of ACh by anticholinergic drugs produce bronchodilation and also reduce the volume of respiratory secretion.
• Less effective bronchodilator than sympathomimetic.
• ADR: Dry mouth, respiratory tract discomfort
Leukotriene antagonistsMontelukast, Zafirlukast
• Block the cys-leukotrienes C4, D4 and E4 (LTC4, LTD4, LTE4)
• Alternative for inhaled glucocorticoids• Prophylactic therapy for mild, moderate asthma; not used for
terminating asthma.• Both are very safe drugs and ADRs are few (headache, rashes);
eosinophilia and neuropathy are infrequent. Few cases Churg-Strauss syndrome (vasculitis with eosinophilia) have been reported.
• Dose: Montelukast 10 mg OD, Zafirlukast 20 mg BD
Leukotriene antagonists• Mechanism of action of leukotriene antagonist, antiinflammatory drugs
Cont.,
Bronchoconstriction, Inflammation, increased mucus
Bronchoconstriction, Inflammation, increased mucus
Bronchoconstriction, Inflammation, PainBronchoconstriction, Inflammation, Pain
Block by steroidal antiinflammatory drugs
Block by steroidal antiinflammatory drugs
Block by nonsteroidal antiinflammatory drugs
Block by nonsteroidal antiinflammatory drugs
Block by Leukotriene antagonists
Block by Leukotriene antagonists
Corticosteroids
• Corticosteroids are not bronchodilators; benefit by reducing bronchial hyperreactivity/mucosal edema and by suppressing inflammation.
• Inhaled glucocorticoids are partially absorbed and because of their systemic AEs systemic glucocorticoids are usually reserved for patients with severe refractory asthma.
• Systemic steroid therapy– Severe chronic asthma: Not contorted by bronchodilator and inhaled steroids. – Status asthmaticus/ acute asthma exacerbation
Mast cell stabilizersSodium cromoglycate, Ketotifen
• Inhibits degranulation of mast cell by trigger stimuli by blocking calcium channels
• Once degranulation has occurred, mast cell stabilizers are ineffective (in the acute setting)
• Long time therapy reduce cellular inflammatory response.
• Pharmacokinetic: – Not absorbed orally. It is administered as an aerosol through metered dose
inhaler delivering 1 mg per dose; 2 puffs 4 times a day– Not popular- production of cough and bronchospasm because of particulate
nature of the inhalation.– Small fraction of the inhaled drug is absorbed systemically and excreted
unchanged form in urine and bile.
Mast cell stabilizers
• Use:– Bronchial asthma: Sodium. Cromoglycate is used as a long term prophylactic in
patients not adequately controlled by inhaled bronchodilators. Alternative for inhaled steroids in mild to moderate asthma but not severe cases.
– Allergic rhinitis: Cromoglycate is not nasal decongestant, regular prophylactic use as a nasal spray produces symptomatic improvement in many patients.
– Allergic conjunctivitis: Regular use as eye drops is benificial in some chronic cases
Cont.,
Adverse effect (cromoglycate):BronchospasmThroat irritationCough, headacheArthralgia, rashes and dysuriaRarely nasal congestion
Adverse effect (Ketotifen):Generally well toleratedSedation and dry mouth Dizziness, nausea and weight gain
Anti-lgE antibody: Omalizumab (Xolair)
• recombinant DNA-derived monoclonal antibody
• Selectively binds to human immunoglobulin E (IgE) and decrease binding affinity of IgE to the high-affinity IgE receptor on the surface of mast cells and basophils, reduce allergic response.
• Omalizumab may be particularly useful for treatment of moderate to severe allergic asthma in patients who are poorly controlled with conventional therapy.
• Due to the high cost of the drug, limitations on dosage, and limited clinical trial data, it is not currently used as firstline therapy.
Acute Management of Acute Management of AsthmaAsthma
Dr. Mohamed Suliman Abdelhamid, Dr. Mohamed Suliman Abdelhamid, PGY-1 PGY-1
Family Medicine Residency Program, Family Medicine Residency Program,
Hamad Medical CorporationHamad Medical Corporation
Status AsthmaticusStatus Asthmaticus
Treatment Treatment – AlbuterolAlbuterol– AtroventAtrovent– SteroidSteroid– TerbutalineTerbutaline– EpinephrineEpinephrine– HelioxHeliox– BIPAPBIPAP– IntubationIntubation– KetamineKetamine– Inhalational anestheticsInhalational anesthetics
Status AsthmaticusStatus Asthmaticus
Severe bronchospasm that does not respond to Severe bronchospasm that does not respond to aggressive therapies within 30-60 minutesaggressive therapies within 30-60 minutes
Severe asthmatic attack with one or more of the Severe asthmatic attack with one or more of the following:following:– Dyspnea (precluding speech), accessory muscle use, Dyspnea (precluding speech), accessory muscle use,
RR 35/minRR 35/min– Hr > 140/minHr > 140/min– Peak expiratory flow < 100 l/min Peak expiratory flow < 100 l/min
– Hypercapnea ( >= 50 mmHg)Hypercapnea ( >= 50 mmHg)
Acute Severe AsthmaAcute Severe Asthma
Critical limitation of expiratory flowCritical limitation of expiratory flow
Increased airway resistanceIncreased airway resistance
Premature airway closurePremature airway closure
Lung and chest wall dynamic Lung and chest wall dynamic hyperinflationhyperinflation
High intrinsic PEEPHigh intrinsic PEEP
Respiratory muscle fatigueRespiratory muscle fatigue
Near-Fatal AsthmaNear-Fatal Asthma
Respiratory arrest or respiratory failure Respiratory arrest or respiratory failure (PCO2 > 50 mmHg)(PCO2 > 50 mmHg)
Fatal AsthmaFatal Asthma
Slow-onsetSlow-onset– Gradual deterioration of asthma symptoms over Gradual deterioration of asthma symptoms over
several days several days – Usually associated with chronic poorly controlled Usually associated with chronic poorly controlled
asthmaasthma– EosinophilicEosinophilic predominance and mucus in predominance and mucus in
submucosasubmucosa
Rapid-onsetRapid-onset– Symptom onset and progression to life-threatening Symptom onset and progression to life-threatening
status within 3 hoursstatus within 3 hours– ““Greater” hypercapneaGreater” hypercapnea– NeutrophilicNeutrophilic predominance in airway submucosa predominance in airway submucosa
The Four Compartments The Four Compartments o o
Respiratory MechanicsRespiratory Mechanics
The lung is not homogenous during acute The lung is not homogenous during acute severe asthmasevere asthmaDriving force for expiratory flow is Driving force for expiratory flow is decreaseddecreasedPersistent activation of inspiratory Persistent activation of inspiratory muscles during expirationmuscles during expiration------– Abnormal low pulmonary elastic recoil Abnormal low pulmonary elastic recoil – High outward recoil of chest wall High outward recoil of chest wall
Resistance to airflow strongly increasedResistance to airflow strongly increased
Respiratory MechanicsRespiratory Mechanics
Markedly prolonged expirationMarkedly prolonged expiration
Inspiration starts before static equilibrium Inspiration starts before static equilibrium is reachedis reached
Positive End-Expiratory alveolar Positive End-Expiratory alveolar PressurePressure– Auto-PEEP (intrinsic PEEP, PEEPi)Auto-PEEP (intrinsic PEEP, PEEPi)
Dynamic HyperinflationDynamic Hyperinflation
Incomplete alveolar emptying at Incomplete alveolar emptying at
the end of expirationthe end of expiration– Intrinsic PEEPIntrinsic PEEP
Measure end-expiratory flow orMeasure end-expiratory flow or
End-expiratory pressureEnd-expiratory pressure
Increased ventilatory requirementIncreased ventilatory requirement
Prolonged expiratory timeProlonged expiratory time
Increased inspiratory threshold loadIncreased inspiratory threshold load
Dynamic HyperinflationDynamic Hyperinflation
Shortening of:Shortening of:– DiaphragmDiaphragm– Inspiratory intercostalsInspiratory intercostals– Accessory musclesAccessory muscles
Decreased mechanical efficiencyDecreased mechanical efficiency– Increased risk of fatigueIncreased risk of fatigue
With increased obstruction:With increased obstruction:– CO2 production > Elimination by alveolar ventilationCO2 production > Elimination by alveolar ventilation
CO2 increasesCO2 increases
Dynamic HyperinflationDynamic Hyperinflation
Mean pleural pressure becomes more Mean pleural pressure becomes more negativenegative– Interstitial pressures are also loweredInterstitial pressures are also lowered– Vascular pressure is maintainedVascular pressure is maintained
The result:The result:– Interstitial edema and further increase in Interstitial edema and further increase in
airway resistanceairway resistance
Asthmatic PatientsAsthmatic Patients
Who do we worry about?Who do we worry about?– Previously intubatedPreviously intubated– Noncompliant or poorly controlledNoncompliant or poorly controlled– Psychosocial or emotional problemsPsychosocial or emotional problems– Frequent flyersFrequent flyers– Environmental triggersEnvironmental triggers
What do we look for on exam?What do we look for on exam?
Severe respiratory distressSevere respiratory distressAccessory muscle useAccessory muscle useMay be hypoxemicMay be hypoxemicTachypneicTachypneicTachycardicTachycardicDiaphoreticDiaphoreticAnxiousAnxious1-2 word dyspnea1-2 word dyspnea
What do we do?What do we do?
Rapid assessmentRapid assessment
Manage the airwayManage the airway
Aggressive treatmentAggressive treatment
Respiratory therapist at bedsideRespiratory therapist at bedside
Have all the needed equipment at the bedsideHave all the needed equipment at the bedside– Intubation…Intubation…
Team approachTeam approach
2 IVs2 IVs
TreatmentTreatment
Albuterol nebAlbuterol neb
Atrovent nebAtrovent neb
Methylprednisolone 125 mg IVMethylprednisolone 125 mg IV
Terbutaline Terbutaline – 0.25 mg SQ q20 minutes x 3 doses0.25 mg SQ q20 minutes x 3 doses
EpinephrineEpinephrine– 1:1000, 0.3 mg SQ or IM q20 minutes x 3 doses1:1000, 0.3 mg SQ or IM q20 minutes x 3 doses
Magnesium sulfateMagnesium sulfate
MgSO4MgSO4
Possible inhibition of calcium influx into Possible inhibition of calcium influx into airway smooth muscleairway smooth muscle
Inhibits cholinergic neuromuscular Inhibits cholinergic neuromuscular transmissiontransmission
Stabilization of mast cells and T Stabilization of mast cells and T lymphocyteslymphocytes
Stimulation of nitric oxide and prostacyclinStimulation of nitric oxide and prostacyclin
PregnancyPregnancy
EpinephrineEpinephrine– Concern re: alpha effect and vasoconstriction in Concern re: alpha effect and vasoconstriction in
uteroplacental circulationuteroplacental circulation– Avoid during pregnancy except in anaphylaxisAvoid during pregnancy except in anaphylaxis
TerbutalineTerbutaline– Preterm laborPreterm labor
High dose steroids in animal studies:High dose steroids in animal studies:– ??? cleft palate??? cleft palate
Palatal closure usually by 12Palatal closure usually by 12thth week week
Albuterol, Atrovent safeAlbuterol, Atrovent safe
PedsPedsAcute severe asthmaAcute severe asthma
Albuterol Albuterol – 0.15mg/kg/hr 0.15mg/kg/hr
Albuterol continuous: Albuterol continuous: – 20 mg/hr if > 20 kg20 mg/hr if > 20 kg
Atrovent Atrovent – 0.5 mg/dose if > 20 kg or > 6y.o.0.5 mg/dose if > 20 kg or > 6y.o.
MgSO4 MgSO4 – 25-75 mg/kg IV25-75 mg/kg IV
Terbutaline Terbutaline – 10 mcg/kg IV over 10 minutes10 mcg/kg IV over 10 minutes – Infusion of 0.1-10 mcg/kg/minInfusion of 0.1-10 mcg/kg/min
HelioxHeliox
Usually 70% Helium: 30% oxygenUsually 70% Helium: 30% oxygen– Inert gasInert gas– 3X reduction in density compared to air3X reduction in density compared to air
Reduces resistance in airways with nonlaminar flow Reduces resistance in airways with nonlaminar flow – Upper and ProximalUpper and Proximal
Reduces respiratory muscle workReduces respiratory muscle workMay improve gas exchangeMay improve gas exchangeMay increase the mass ofalbuterol delivered May increase the mass ofalbuterol delivered – Allows smaller particles to better penetrate the lung peripheryAllows smaller particles to better penetrate the lung periphery
May use with:May use with:– Face maskFace mask– BIPAPBIPAP– Mechanical ventilationMechanical ventilation
CPAPCPAP
Seems to increase Functional residual Seems to increase Functional residual capacity and lung compliancecapacity and lung compliance
May decrease fatigue of respiratory May decrease fatigue of respiratory musclesmuscles
Decreases the adverse hemodynamic Decreases the adverse hemodynamic effects of large negative inspiratory swings effects of large negative inspiratory swings in pleural pressure which compromise RV in pleural pressure which compromise RV and LV performanceand LV performance
BIPAPBIPAP
Provides CPAPProvides CPAP
Delivers higher pressure in inspiration than Delivers higher pressure in inspiration than expirationexpiration
When to IntubateWhen to Intubate
When do you intubate an asthmatic When do you intubate an asthmatic patient?patient?
Persistent hypercarbiaPersistent hypercarbia
Hemodynamic instabilityHemodynamic instability
Inability to tolerate the face mask, BIPAP..Inability to tolerate the face mask, BIPAP..
ExhaustionExhaustion
Altered mental status….Altered mental status….
SummarySummary
Look for the “sick” asthmaticsLook for the “sick” asthmaticsBe aggressive in their treatmentBe aggressive in their treatmentDo not forget about Do not forget about – Terbutaline ( SQ)Terbutaline ( SQ)– Epi ( SQ or IM)Epi ( SQ or IM)
If they are young and “fighting”, consider:If they are young and “fighting”, consider:– BIPAPBIPAP– HelioxHeliox– IV EpinephrineIV Epinephrine
Intubate if the patient is:Intubate if the patient is:– FatiguedFatigued– Unable to cooperate with interventionsUnable to cooperate with interventions
Thank YouThank You
Dr. Mostafa Hamdy Rashed, PGY-1 Family Medicine Residency Program, Hamad Medical
Corporation
Levels of Asthma Control
CharacteristicControlled
(All of the following)
Partly controlled(Any present in any
week)Uncontrolled
Daytime symptomsNone (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities
None Any
Nocturnal symptoms / awakening
None Any
Need for rescue / “reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Exacerbation None One or more / year 1 in any week
Goals of Long-term Management
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and PreventionAsthma Management and PreventionProgram: Five ComponentsProgram: Five ComponentsAsthma Management and PreventionAsthma Management and PreventionProgram: Five ComponentsProgram: Five Components
Asthma Management and Prevention Program
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
.
Asthma Management and Prevention Program
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Component 1: Develop Patient/Doctor Partnership Component 1: Develop Patient/Doctor Partnership
Component 1: Develop Patient/Doctor Partnership Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Component 1: Develop Patient/Doctor PartnershipComponent 1: Develop Patient/Doctor Partnership
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.
Factors Involved in Non-AdherenceFactors Involved in Non-Adherence
Medication Usage Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Medication Usage Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Component 2: Identify and Reduce Exposure to Risk FactorsComponent 2: Identify and Reduce Exposure to Risk Factors
Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.
Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.
Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.
Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma
development, especially in children and young infants
Component 2: Identify and Reduce Exposure to Risk FactorsComponent 2: Identify and Reduce Exposure to Risk Factors
Influenza VaccinationInfluenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised.
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
Depending on level of asthma control, the patient is assigned to one of five treatment steps
Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
Controller MedicationsController Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids
Reliever MedicationsReliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest controlling step
consider stepping up to gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Step 4 – Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)
Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
When control as been achieved, ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored by the health care professional and by the patient
Levels of Asthma Control
CharacteristicControlled
(All of the following)
Partly controlled(Any present in any
week)Uncontrolled
Daytime symptomsNone (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities
None Any
Nocturnal symptoms / awakening
None Any
Need for rescue / “reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Exacerbation None One or more / year 1 in any week
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)
When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.
Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)
Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)
Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
Children 5 Years and YoungerChildren 5 Years and Younger
Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
Children 5 Years and YoungerChildren 5 Years and Younger
Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children
These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children
These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
Children 5 Years and YoungerChildren 5 Years and Younger
Special ConsiderationsSpecial Considerations
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
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