1) What is bronchial asthma?

Bronchial asthma (also called reversible airway obstruction) is a clinical

syndrome characterized by recurrent bouts of Bronchospasm. There is
increased responsiveness of the tracheo-bronchial smooth muscles to various
stimuli resulting in widespread narrowing of the airway.

2) How is asthma clinically identified?

Triad:
I. Episodic Wheezing
II. Cough
III. Dyspnoea

3) How is asthma differentiated from COPD clinically?

COPD is clinically defined by a low FEV1 value that fails to respond acutely to
bronchodilators, a characteristic that differentiates it from asthma.

4) What is the treatment strategy of bronchial asthma?

I. Avoid exposure (allergens, noxious stimuli)
II. Treat inflammation
III. Dilate bronchi

5) What are the two broad categories for pharmacological treatment of

asthma? (What are their principles and when can they be taken?)
I. Relievers
- Cause bronchodilation (Act only on airway smooth muscle spasm)
- Acutely decreases symptoms (Cough, SOB, Wheeze/Tightness)
- Taken: when necessary
Short-acting agonists:
1. Salbutamol (Albuterol)
2. Fenoterol
3. Terbutaline

Anti-cholinergics
1. Ipratropium bromide

II. Controllers
- Treat the underlying inflammation (and/or cause prolonged
bronchodilation)
- Decreases symptoms (mucosal swelling, secretions, irritability of
bronchial smooth muscle)
- Taken: regularly (even when well)
- For: All asthmatics, EXCEPT mild intermittent
Inhaled Corticosteroids:
1. Beclomethasone
2. Budesonide
3. Fluticasone

Oral Corticosteroids:
1. Prednisone
 2. Prednisolone
3. Methylprednisone
4. Methylprednisolone

Leukotriene modifiers:
1. Montelukast
2. Zafirlukast

Long-acting agonists:
1. Salmeterol
2. Formoterol

Theophylline (sustained release)

6) When would you prescribe Omalizumab?

Omalizumab is a biologic drug that targets and blocks the antibody
immunoglobulin E (IgE), a chemical trigger of the inflammatory events
associated with an allergic asthma attack.

It is used only to treat patients who have moderate-to-severe persistent

asthma related to allergies whose symptoms are not controlled by inhaled
corticosteroids.

7) Why do aspirin and NSIDs precipitate asthma?

Attacks of asthma precipitated by aspirin like drugs are due to the inhibition
of COX in airways of the sensitive patients.
The two major enzymes in the COX pathway are cyclo-oxygenase 1 and 2
(COX-1 and COX-2 respectively). Most of the evidence suggests that inhibition
of COX-1 is related to the pathogenesis of AIA (Aspirin Induced Asthma) in
patients sensitive to aspirin. It is thought that this inhibition causes a
deficiency in the protective bronchodilator/anti-inflammatory prostaglandins,
and an excess of pro-inflammatory/bronchoconstrictive leukotrienes,
specifically cysteinyl-leukotrienes.

8) Why are -2 agonists given when the innervation is muscarinic?

The lungs are innervated by both the sympathetic and parasympathetic

nervous systems, which entails the activation of adrenergic and muscarinic
receptors, respectively.
A 2 agonist is given -> SNS
An Anti-muscarinic agent (e.g. Ipratropium) is given -> PSNS
9) Can drugs be combined? If so which would combine?
Long acting 2 agonist + Inhaled Corticosteroid
Ipratropium + Salbutamol (in refractory asthma)
 Theophylline + Inhaled Corticosteroid (Theophylline may enhance the
anti-inflammatory action of inhaled corticosteroids)

10) Describe the steps in the treatment of asthma.

Step I: Mild intermittent asthma (symptoms are less than once

daily, <2 per week)
- Occasional inhalation of a short acting Beta-2 agonist salbutmol,
terbutaline.
If used more than once daily -> step II
Step II: Mild persistent asthma (symptoms are >2 per week but not
every day)
- Regular inhalation of low-dose steroids. Alternatively,
cromoglycates.
- Beta-2 agonist as and whenever required
Step III: Moderate persistent asthma (Symptoms occur daily.
Inhaled short-acting -2 agonist is used every day.)
- Inhalation of high dose of steroids (800 mcg) + Beta-2 agonist.
- Sustained release theophylline may be added.
- LT inhibitors may be tried instead of steroids
- spacers
Step IV: Severe persistent asthma (symptoms occur throughout
each day)
- Higher dose of steroid (800 to 200 mcg) + regular long-acting beta-
2 agonist (salmeterol)
- Additional treatment with oral drugs LT antagonist or SR
theophylline or oral beat-2 agonist

11) What is status asthmaticus & how is it treated?

Status asthmaticus is an acute exacerbation of asthma that remains
unresponsive to initial treatment with bronchodilators.

Treatment:
Oxygen
Inhaled albuterol;
Intravenous or oral corticosteroids (Hydrocortisone hemisuccinate)
Inhaled anticholinergics (Ipratropium bromide)
Antibiotics
IV saline