ASTHMA

By:
Rey Martino

(for educational use only)

Definition

 chronic inflammatory disorder of the airways

 infiltration of mast cells, eosinophils and

lymphocytes

 wheeze, cough, chest tightness and shortness

of breath
 symptoms vary over time and in severity

 widespread, variable and reversible airflow

limitation

 airway hyper responsiveness

Epidemiology
• Common disease
• In Malaysia, prevalence of asthma :
Primary school children :13.8%
Children aged 13-14 :9.6%
Adults :4.1%

• In Taiwan, the prevalence of asthma

symptoms has increased almost five-fold
over a 20-year period
• In Japan the number of asthma patients
treated by medical facilities today is over
100 cases per day, per 100,000 people—
just 30 years ago it was 3 cases per day,
per 100,000.
 Comparisons of asthma & COPD
Patho- Asthma COPD
physiology:  CD 4+ lymphocytes  CD 8+ lymphocytes
chronic  eosinophils  macrophages
inflammation
 mast cells  neutrophils

Clinical
history: Vary over time and in Persistent and progressive
severity over time
symptoms
 cough  cough
 wheeze  sputum
 chest tightness  breathlessness
 breathlessness  wheeze
Asthma and COPD

Asthma COPD
population population

10% of patients
have both
conditions
 Modern view of asthma
Allergen

Macrophage/
dendritic cell Mast cell

Th2 cell Neutrophil

Eosinophil
Mucus plug
Epithelial shedding
Nerve activation

Subepithelial
fibrosis
Plasma leak
Sensory nerve
Oedema activation
Vasodilatation Cholinergic
Mucus reflex
New vessels
hypersecretion
Hyperplasia Bronchoconstriction
Hypertrophy / hyperplasia
Factors that Exacerbate Asthma

 Allergens
 Air Pollutants
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
Asthma Diagnosis
 History and patterns of symptoms
 Physical examination
 Measurements of lung function
 Measurements of allergic status to identify
risk factors
Consider asthma if any of the following signs or symptoms are present.
• Wheezing–high-pitched whistling sounds when breathing out–
especially in children.

• History of any of the following:

• Cough, worse particularly at night
• Recurrent wheeze
• Recurrent difficult breathing
• Recurrent chest tightness.

• Symptoms occur or worsen at night, awakening the patient

Symptoms occur or worsen in the presence of:

• Animals with fur
• Exercise
• Aerosol chemicals
• Pollen
• Changes in temperature
• Respiratory (viral) infections
• Domestic dust mites
• Smoke
• Drugs (aspirin, beta blockers)
• Strong emotional expression
• Reversible and variable airflow limitation–as measured by using a spirometer
(FEV1 and FVC) or a peak expiratory flow (PEF) meter. When using a peak
flowmeter, consider asthma if:
• PEF increases more than 15 percent 15 to 20 minutes after inhalation of
a rapid-acting 2-agonist, or

• PEF varies more than 20 percent from morning measurement upon

arising to measurement 12 hours later in patients taking a bronchodilator
(more than 10 percent in patients who are not taking a bronchodilator), or

• PEF decreases more than 15 percent after 6 minutes of sustained

running or exercise.
 Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF

Symptoms
STEP 4 Continuous  60% predicted
Severe Limited physical Frequent Variability > 30%
Persistent activity

STEP 3 Daily 60 - 80% predicted

Attacks affect activity > 1 time week Variability > 30%
Moderate
Persistent
STEP 2  80% predicted
> 1 time a week > 2 times a month
Mild Variability 20 - 30%
Persistent but < 1 time a day

< 1 time a week

STEP 1  80% predicted
Asymptomatic and  2 times a month
Intermittent normal PEF Variability < 20%
between attacks
The presence of one feature of severity is sufficient to place patient in that category.
 Pharmacological therapy
Relievers
 inhaled fast-acting
ß2-agonists
 inhaled anticholinergics
Controllers
 inhaled corticosteroids
 inhaled long-acting ß2-
agonists
 inhaled cromones
 oral anti-leukotrienes
 oral theophyllines
 oral corticosteroids
RELIEVERS MEDICATION

– Quick relief medicine or rescue medicine.

– Rapid acting bronchodilators that act to relieve

bronchoconstriction.
 Short-acting inhaled B-agonist
• Use intermittently to control episodes of
bronchoconstriction
• Avoid regular scheduled use if possible
• An increase use is an indication of
deteriorating control
 LONG ACTING 2 AGONIST

• Mechanism of action:
– Bronchodilator
– Enhance mucociliary clearance
– Modulate mediators release from mast cells and
basophils

• Example : Inhaled : Salmeterol , formeterol

Oral : Bambuterol
Salbutamol SR
Terbutaline SR
Clenbuterol
 LONG ACTING 2 AGONIST

• Inhaled 2 Agonists have fewer side effects than oral

formulations.

• Side-effects : tachycardia, palpitations, tremors, anxiety,

headache and hypokalaemia.
 CONTROLLER MEDICATIONS
• Are medications taken daily on a long term basis that
are useful in getting and keeping persistent asthma
under control.
• Prophylactic, preventive or maintenance medications
• Include
» Inhaled glucocorticosteroids
» Systemic glucocorticosteroids
» Theophylline
» Long acting inhaled 2 agonist
» Long acting oral 2 agonist
» Leukotriene modifiers
 GLUCOCORTICOSTEROIDS
• Mechanisms of action :

– Reduced airway inflammation

– Efficacy in improving lung function, decreasing airways

hyperresponsiveness, reducing symptoms, reducing
frequency and severity of exacerbations and improving
quality of life.
 GLUCOCORTICOSTEROID
• Inhaled : Beclomethasone
Budesonide
Fluticasone

• Oral : Prednisolone
Dexamethasone

• Parenteral : Hydrocortisone
Methylprednisolone
• Side effects
– Local effects –
• oropharyngeal candidiasis, dysphonia, upper airway irritation
• How to prevent ? – Mouth washing after inhalation & use of spacer

– Systemic adverse
• effects depends on the dose and potency of glucocrticosteroids ,
absorption in the gut, first past effect of liver.
• Systemic adverse effects include : skin thinning, easy bruising,
cataract, obesity, adrenal suppression, hypertension, diabetes
and myopathy.
 METHYLXANTHINES

• Mechanism of action: Antiinflammatory

effects & bronchodilator.
• Side effects :
– GIT Symptoms – nausea, vomiting
– CVS Symptoms – tachycardia, arrhythmias
– Drug interaction : Erythromycin, cimetidine and
rifampicin
 Anti-cholinergics
• Inhaled ipratropium bromide.

• Mechanism of action : Bronchodilator.

• Efficacy : Bronchodilator actions are less potent

than those of inhaled ß2-agonists, slower onset
of action which peaks 30 – 60 min.

• Side-effect : Dry mouth.

LEUKOTRIENE MODULATORS

• MECHANISM OF ACTION :
– Block the synthesis of all leukotrienes

• Example : montelukast ( Singulair ),

Zafirlukast
Levels of asthma control
GINA 06’
 Emergency Department Management

Acute Asthma
Initial Assessment
History, Physical Examination, PEF or FEV 1

Initial Therapy
Bronchodilators; O2 if needed
Good Response
Incomplete/Poor Response Respiratory Failure

Observe for at Add Systemic Glucocorticosteroids

least 1 hour
Good Response Poor Response
If Stable,
Discharge to Discharge Admit to Hospital Admit to ICU
Home
Thank
You…

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