Bronchial Asthma

Asthma Case Presentation

 Mr X a 30 year old gentleman

Smoker 8 pack years
Is a known case of childhood bronchial
asthma but not on follow up and buys his
MDI from pharmacy.
No previous history of admission

Presented with :
Shortness of breath for 2 days
Claims started with cough, which was
productive with whitish sputum
Apart from cough no other URTI symptoms
Patient denied any fever, UTI or AGE
symptoms
No chest pain, reduced effort tolerance or
orthopnea or PND
Went to KK and was given neb 2x and as still
SOB so came to ETD where he was given neb
4x, since he still had SOB and rhonchi on lung
auscultation patient was admitted.

Asthma history :
Childhood onset (patient unsure of age )
No eczema or allergic rhinitis
Denied night symptoms
Has daytime symptoms 2x per week
Claim uses inhalers : MDI salbutamol and
MDI beclomethasone
Trigger : dust, physical exertion and URTI
If symptoms not alleviated with MDI
patient goes to KK for neb.
This year, so far he has been to KK for
neb 10 times.

 On examination :
He was alert, able to speak full sentences
and not tachypnoeic
Not in respiratory distress
Good pulse volume
BP : 135/73, PR : 128, SPo2 : 97% under
room air, afebrile
Lungs : Bilateral rhonchi heard but no
crepitations and air entry equal
CVS : DRNM
ABG : no respiratory failure
Chest X-ray : noted clear
His FBC and BUSE were normal.

 In ward :
Patient was given neb 4 hourly
Patient given T.prednisolone 30mg OD,
MDI Salbutamol 2 puff PRN, MDI
Beclomethasone 2puff BD
PEFR monitoring
Then his MDI technique were assessed
Patient was advised to stop smoking and
to go for regular follow up at KK for review
of his asthma.

Discharged with :
MDI salbutamol 2 puff PRN x 2/12
MDI beclomethasone 2 puff BD x 2/12
Patient to TCA at his nearest KK in 2
months time to review asthma symptoms.

Definition
Bronchial asthma is a chronic inflammatory disorder of
the airways associated with airway hyperresposinveness
that present with :

wheezing
breathlessness
chest tightness
night time or early morning cough

The inflammation is characterised by oedema, infiltration

with inflammatory cells especially eosinophils,
hypertrophy of glands and smooth muscle and damaged
epithelium
the airway obstruction caused is resversible either
spontaneiously or with treatment

 Usually bronchial asthma manifest itself

early during childhood period, with rare
occasions of the onset during adulthood.
the patient may or may not present with
history of exposure to allergen .

 The diagnosis of asthma is based on the

recognition of a characteristic pattern of
symptoms and signs and the absence of
an alternative explanation for them
The key is to take a careful clinical history.
In many cases this will allow a reasonably
certain diagnosis of asthma,or an
alternative diagnosis, to be made.

Lung Function Test

Lung function tests (also called pulmonary
function tests, or PFTs) check how well your
lungs work.
The tests determine how much air your lungs
can hold, how quickly you can move air in and
out of your lungs, and how well your lungs put
oxygen into and remove carbon dioxide from
your blood.
The tests can diagnose lung diseases, measure
the severity of lung problems, and check to see
how well treatment for a lung disease is working.

Spirometry
Spirometry is the first and most commonly
done lung function test.
It measures how much and how quickly
you can move air out of your lungs.
For this test, you breathe into a
mouthpiece attached to a recording device
(spirometer).
The information collected by the
spirometer may be printed out on a chart
called a spirogram.

 Attach a clean, disposable, one-way mouthpiece to the spirometer (a fresh

one for each patient).
Ask the patient to breathe in as deeply as possible (full inspiration).
The patient should hold their breath just long enough to seal their lips. The
patient should NOT purse their lips as if blowing a trumpet, and ideally
should pinch their nose or wear a nose clip.
The patient should now blow the breath out, forcibly, as hard and as fast as
possible, until there is nothing left to expel:
for patients with severe COPD this can take up to 15 seconds
encourage the patient to keep blowing out
some spirometers give a bleep to confirm the manoeuvre is complete.
Now repeat the procedure, and then repeat it again.
You should have three readings of which the best two are within 100ml, or 5%,
of each other.
Depending on your model of spirometer the results may appear on a display
(which you may be able to store against the date and time) or may be
printed.

Radiography
The value of chest radiography is in
revealing complications or alternative
causes of wheezing and the minor
importance of wheezing in the diagnosis of
asthma and its exacerbations.
It usually is more useful in the initial
diagnosis of bronchial asthma than in the
detection of exacerbations, although it is
valuable in excluding complications such
as pneumonia and asthma mimics, even
during exacerbations.

Posteroanterior chest radiograph demonstrates a pneumomediastinum in

bronchial asthma. Mediastinal air is noted adjacent to the anteroposterior
window and airtrapping extends to the neck, especially on the right side

Lateral chest radiograph

demonstrates a
pneumomediastinum in bronchial
asthma. Air is noted anterior to the
trachea (same patient as in the
previous image).

Treatment of Asthma

Drug treatment
There are 2 major groups of drugs to treat
asthma:
1.Bronchodilator drugs - to relieve
bronchospasm and improve symptoms.
2.Anti inflammatory drugs - to treat the
airway inflammation and bronchial
hyperresponsiveness, the underlying
cause of asthma, i.e. to prevent attacks.

A) Bronchodilators
There are 3 main groups of bronchodilators:
a. Beta2 agonists
b. Anticholinergics
c. Methylxanthines

Beta2 agonists
The therapeutic effect is felt within a few minutes of inhalation. The main side
effects are tremors and tachycardia. Oral slow release preparations and
inhaled long acting beta2 agonists such as Salmeterol /bambuterol are useful
for nocturnal asthma.
Examples: Inhaled beta2 agonist:
salbutamol (Ventolin, Respolin)
terbutaline (Bricanyl)
fenoterol (Berotec)
salmeterol (Serevent) - long acting
Oral long acting beta2 agonist:
salbutamol (Volmax)
terbutaline (Bricanyl durules)
bambuterol (Bambec)
Oral short acting beta2 agonist:
salbutamol
terbutaline etc.

Anticholinergic drugs
Inhaled anticholinergics have lower onset
but longer duration of action. They have
very few side effects.
Example: Ipratropium bromide (Atrovent)

Methylxanthines
These drugs are available in oral and
parenteral forms. Sustained release
preparations may be useful in nocturnal
asthma.
Examples: Nuelin SR, Theodur, Euphylline

B) Anti-Inflammatory Drug
i. Corticosteroids
Steroids are the main prophylactic drugs in adult asthmatics. They
should be taken by inhalation and the 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 (Becotide, Becloforte,
Beclomet, Aldecin, Respocort) Budesonide (Pulmicort)
ii. Sodium cromoglycate (Intal)
This drug is very safe with no significant side effects. It is given by
inhalation (power Spinhaler or metered dose inhaler). It is of greatest
benefit in young, atopic patients.

Exacerbation
Exacerbations are characterised by decreases in expiratory
airflow that can be quantified by measurement of lung
function with spirometry (FEV1) or peak flow (PEF). These
measurements are more reliable indicators of the severity
of airflow limitation than symptoms.
Milder exacerbations, defined by a reduction in peak flow of
less than 20%, nocturnal wakening and increased use of shortacting 2-agonists can usually be treated in a community
setting. If the patient responds to the first few doses of inhaled
bronchodilator therapy, referral to an acute facility is not
required, but further management may include the use of
systemic glucocorticosteroids. Patient education and review of
maintenance therapy should be undertaken.

The primary therapies for exacerbation to

relieve airflow obstruction and hypoxemia
are:
Repetitive administration of rapid-acting
inhaled 2-agonist bronchodilator
Early introduction of systemic
glucocorticosteroids
Oxygen supplementation
The clinician can decide if antibiotic
therapy is appropriate

Bronchodilators repeated administration of rapidacting inhaled 2-agonist

Bronchodilator therapy delivered via a metered-dose inhaler(MDI),

ideally with a spacer, produces at least an equivalent improvement
in lung function as the same dose delivered via nebuliser.
This route of delivery is the most cost effective, provided patients
are able to use an MDI.
Response to treatment may take time and patients should be
closely monitored using clinical as well as objective measurements.
The increased treatment should continue until measurements of
lung function (PEF or FEV1) return to their previous best (ideally) or
plateau, at which time a decision to admit or discharge can be made
based upon these values.
Patients who can be safely discharged will have responded within
the first two hours, at which time decisions regarding patient
disposition can be made.

Global strategy for asthma management and

prevention: GINA executive summary

SEEVERITY OF ASTHMA

PREVENTION OF ASTHMA
ASTHMA PREVENTION
AIMED AT THE PREVENTION OF ALLERGIC
SENSITIZATION
PREVENTION OF ASTHMA DEVELOPMENT
IN SENSITIZED PEOPLE
ROLE OF DIET
H1-ANTAGONISTS (ANTIHISTAMINES)
ALLERGEN-SPECIFIC IMMUNOTHERAPY

PREVENTION OF ASTHMA
SYMPTOMS AND
EXACERBATIONS

INDOOR ALLERGENS

 OUTDOOR ALLERGENS
AIR POLLUTANTS (INDOOR OR
OUTDOOR)
OCCUPATIONAL EXPOSURES
FOOD AND FOOD ADDITIVES
DRUGS
INFLUENZA VACCINATION
OBESITY
EMOTIONAL STRESS
OTHER FACTORS

Thank you