Asthma

contents
1 Epidemiology
2 2 Definition
3 Aetiology and Pathogenesis
4 Pathology
5 Clinical features
6 Diagnosis
7 Complication
8 Treatment
9 Education and Management
1 Epidemiology
–City >countryside
–Children>adults
–1.6 million in China
–1.5 billion in the World
– China:1%~4%
 GINA
• In1993, NHLBI
collaborated with the
WHO to convene a
workshop that led to the
Global Strategy for
Asthma, a programm
called :
the Global
Initiative for
Asthma (GINA).
 2 Definition
① Asthma is a chronic
inflammatory disorder of
the airways in which many
cells and cellular elements
play a role.
②The chronic inflammation
causes an associated increase
in airway hyperresponsiveness
that leads to recurrent episodes
of wheezing, breathlessness,
chest tightness, and coughing,
particularly at night or in the
early morning.
③These episodes are usually
associated with widespread
but variable airflow obstruction
that is often reversible either
spontaneously or with
treatment.
 three key points:
• Chronic airway inflammation
• Broncho-
hyperresponsiveness, BHR
• Reversible airflow limitation
 Airway inflammation theory of
asthma
• Old theory –airway spasm
–relieve bronchoconstriction
• New theory -- Airway inflammation
– exacerbation stage: relieve
bronchoconstriction + anti-inflammatory
treatment
– catabasis: long time anti-inflammatory
treatment to control the outbreak of asthma
 Essence of asthma:
inflammation
• Inflammation: • Infection:
eosinophils and leucocyte
lymphocytes
• Anti- • Antibiotic
inflammatory
drugs:
Glucocorticoid
3 Aetiology

Pathogenesis
 Risk factors

Environmental factors
Host factors
Indoor allergens

(Genetic factors) Outdoor allergens

Tobacco smoke
Genetic predisposition
Occupational sensitizers
Atopy Air pollution

Airway Respiratory infections

Parasitic infections
hyperresponsiveness
Socioeconomic status
Gender Family size

Race/ethnicity Diet and drugs

Obesity
pollens
Pathogenesis: not very clear

the main mechanisms are:

–Airway inflammation
–Allergy
–Airway
hyperresponsiveness
–Neuromechanism
• IAR: (Immediate asthmatic reaction)
– begins within minutes of contact with the
allergen,
– reaches its maximum in 15-20 minutes
– subsides by 1 hour.
• LAR : (late asthmatic reaction)
– following IAR,
– onset in 6 hours after inhaling allergen,
– symptoms are severe and will last many days.
• DAR: (Dual asthmatic reaction)
– is a combination of IAR followed by LAR.
4 Pathology
Smooth muscle mucus
hypertrophy plugs

epithelial
goblet cells
increased
epithelial disruption

eosinophils
lymphocytes

mast cell
• the lung is over inflated,
• both large and small airways being
filled with mucus plugs (comprised of
a mixture of mucus, serum proteins,
inflammatory cells, and cell debris.)
• extensive infiltration of the airway
lumen and wall with eosinophils and
lymphocytes
• vasodilatation, microvascular leakage,
• smooth muscle hypertrophy,
• new vessel formation,
• increased numbers of epithelial
goblet cells,
• epithelial disruption
5 Clinical features
⑴Symptoms :
expiratory wheezing
chest tightness
coughing
shortness of breath
 expiratory wheezing
• It occurs suddenly and is episodic ,
• usually it occurs and becomes
severity at night or in the early
morning.
• the attacks maybe to last only a few
minutes or several days.
• some patients relieve spontaneously
or as a result of treatment.
 Why its often worse
at night or in early morning
the main reason are
–gastroesophageal reflux
–the regulate of the nerve in day
and night include:
–Pneumogastric nerves、
–Sympathetic
–Parasympathetic nerve.
⑵Physical Examination
– the lung becomes over inflated
– the time of expiratory prolonged
– the rate of respiratory becomes rapid
– can hear whistling (or rhonchi ,mainly
high pitched and when breath out the
air) in the whole chest
– silent chest (wheezing may be absent
in severe asthma)
other physical sign severity,
such as:
– cyanosis,
– drowsiness,
– difficulty speaking,
– tachycardia,
– hyperinflated chest,
– Use of accessory muscles,
Blood and sputum tests
• in peripheral blood: the number of
eosinophils (＞0.4×109/L).
white blood cell (if combine with
infection)
• in the sputum: eosinophils
if patient without sputum :
may use hypertonic saline --- to
induced sputum through nebulizer,
 Chest X-ray
• Normal: between episodes
• Thoracic hyper inflated: in an
acute onset or in chronic severe
disease
• Emphysema: in chronic case
 Arterial blood gas
• Should be performed in patients with
acute severe asthma.

PaO2 PaCO2 pH
Mild
Moderate normal normal
Severe
Measurements of Lung
Function
• FEV1 forced expiratory
volume in the first
second
• PEF peak expiratory flow
• FVC forced vital capacity
• FEV1/FVC% it is a ratio
 there are three tests usually be
used in diagnosing asthma
①、bronchial provocation test (BPT)

②、bronchial dilation test (BDT)

③、peak expiratory flow (PEF)

bronchial provocation test, BPT
–FEV1 variability>20% ,BPT
positive.
–have low specificity
• negative test: exclude a diagnosis
of persistent asthma
• positive test: does not always
mean that a patient has asthma.
bronchial dilation test ,BDT
–FEV1 variability≥15%
and increased absolute value of
FEV1＞200ml,
BDT positive
–To measure reversibility of
airway
–Inhale bronchodilator: β2-
adrenoceptor agonists
peak expiratory flow (PEF) variability

• If improvement of PEF ≥ 15 % after

inhalation of a bronchodilator or in
response to a trial of Glucocorticoid
therapy favors a diagnosis of asthma.
• If a diurnal variation in PEF ≥ 20 %,
is considered to be diagnosis of
asthma,
峰流速仪的正确使用

① ②

③ ④

Just like a child to

blow candles in
her birsday
6 Diagnosis
 Diagnosis standard
（1）recurrent attacks of
wheezing, breathlessness, cough
and (or) chest tightness，and
often following exposure to
airborne allergens or pollutants,
cold wheather, viral infections of
upper respiratory tract, exercise…
(2) Physical examination:
expiratory whistling in the
two lungs sporadic or
diffusely
(3) all the symptoms and
physical examination involve
(1) and (2) may improved by
appropriate anti-asthmatic
treatment or spontaneously .
(4) excluding the other
diseases which can lead to
wheezing, cough,
breathlessness and chest
tightness
(5) If the clinical features are not
representative (e.g without
wheezing or signs), at least
one of the next three test must
be presence:
① bronchial provocation test positive ;
② bronchial dilation test positive ;
③PEF variability≥20%.
Asthma can be diagnosed
consistent with:
(1)+(2)+(3)+(4),
or consistent with :
(4)+(5) .
particularly asthma

–Occupational Asthma
–Seasonal Asthma
–Aspirin induced asthma
–Cough Variant Asthma
–Nocturnal asthma
 Classification of Asthma
According to the degree of symptoms,
signs and lung function, we classify the
asthma into three stages:

⑴ exacerbation stage
⑵ chronic persistent stage
⑶ catabasis
7 Complication
–Pneumothorax
–Emphysema
–Chronic bronchitis
–Bronchiactasis
 8 Treatment
Goal
• Achieve and maintain control of symptoms
• Prevent asthma exacerbations
• Maintain pulmonary function as close to normal
levels as possible
• Maintain normal activity levels, including
exercise
• Avoid adverse effects from asthma medications
• Prevent development of irreversible airflow
limitation
• Prevent asthma mortality.
① Nonpharmacologic therapy
② Medications
③ treatment of exacerbation stage
④ long-term medications
① Nonpharmacologic therapy

• Avoidance of triggering
factors
–e.g. milk , paint , drugs
(salicylates, sulfites, aspirin )
• Desensitization treatments
are limited.
 ② Medication
– Bronchodilator
• reliever medications
• quick relief medications
– Anti-inflammatory drugs
• controller medications
• long-term contral medications
 Bronchodilator
–Bronchodilators act principally
to dilate the airways by
relaxing airway smooth muscle
–Act quickly to relieve
bronchoconstriction and its
accompanying acute symptoms
 Bronchodilator
• β2-adrenoceptor agonists
– is the preferred drugs for
controlling acute occuring
symptoms
• Theophylline (aminophylline)
• Anticholinergic
• Others: Epinephrine;
β2-adrenoceptor agonists
• Short-acting: activity that persists
for at least 4~6 hours
– salbutamol
– terbutaline
– fenoterol
• long-acting: activity that persists
for at least10~ 12 hours
– procaterol
– salmaterol
– bambuterol
– formoterol (new)
• Side effects
–Therapy with long-acting inhaled
β2-agonists causes fewer
systemic adverse effects,
such as :
• cardiovascular stimulation,
• skeletal muscle tremor,
• and hypokalemia–than oral therapy.
Route of Administration
–Inhaled: preferred
–Oral: considerable of side
effect
–Intravenous: only when
the other administration is
dimmed
• inhaled advantage
– directly into the airways via inhalation
– is high concentrations at the airways
– The action of bronchodilators is more
effectively and quicker to the airways,
when they are given via inhalation than
orally.
– systemic side effects are avoided or
minimized.
Anti-inflammatory
•Glucocorticoid
•Leukotriene modifiers.
•Cromolyn sodium
•Others: ketotifen; Second-
generation antihistamines
(H1-antagonists)
 glucocorticoid

• suppress airway inflammation

• reduce airway
hyperresponsiveness,
• control and prevent asthma
symptoms
• Inhaled
– beclomethasone
– budesmide
– Flunisolide
– Fluticasone propionate
– Mometasone
– Triamcinolone acetonide
• Oral
– prednisolone
• Intravenous
– methylprednisolone
 Inhaled glucocorticoid
• Is recommend to use on a long-
term basis to achieve and
maintain control of persistent
asthma
• reduce the need for oral
glucocorticoids
• have less systemic impact than
systemic steroids
 Estimated equipotent doses of
Inhaled glucocorticoid (adults)
Mild moderate Severe
persistent persistent persistent
drugs Low dose Medium dose hige dose
(g) (g) (g)

beclomethasone 200~500 500~1000 ＞1000

budesmide 200~400 400~800 ＞800

Fluticasone
100~250 250~500 ＞500
propionate
 Side effects
• thrush
• dysphonia
• adrenal suppression
• growth retardation in children,
• loss of bone mineralization,
• cataracts formation
• glaucoma.
• purpura
 oral glucocorticoid
– Prednisolone
–used for patient defeat in inhaled
glucocorticoid or patient need
short-term strong treatment
–the dose of the beginning is 30 to
60 mg once daily
–reducing the dose less than 10 mg
per day after remission, then stop
or replace by inhaled glucocorticoid
Intravenous glucocorticoid
– Methylprednisolone
–in acute bronchospasms or
exacerbation, use intravenous
glucocorticoid as early as possible
–a usual dose is 80 to 160 mg daily
appear effect after 2~4h
–reducing the dose by one-half
every third to fifth day after an
acute episode ,then maintain by
inhaled or oral glucocorticoid
 ③ Acut severe asthma
• Severe exacerbations of
asthma are life-threatening
medical emergencies.
• Care must be expeditious, and
treatment is often most safely
undertaken in a hospital or a
hospital-based emergency
department.
 9 Education and
Management
1. Educate patients to develop a
partnership in asthma
management
2. Assess and monitor asthma
severity with both symptom reports
and, as much as possible,
measurements of lung function
3. Avoid or control asthma triggers
4. Establish individual
medication plans for long-term
management in children and
adults
5. Establish individual plans for
managing exacerbations
6. Provide regular follow-up care.
End
 atopy
• At the beginning of last century The term atopy was
used to describe a group of disorders, includeing
asthma (and hayfever), by clinicians. that appeared:
– ①to run in families,
– ②to have characteristic wealing skin reactions
to common allergens in the environment,
– ③to have circulating antibody in their serum that
could be transferred to the skin of non-sensitized
individuals.
• atopy is best used to describe those individuals who
readily develop antibodies of IgE class against
common materials present in the environment.
 Glucocorticoid
Any of a group of steroid hormones, such
as cortisone, that are produced by the
adrenal cortex, are involved in
carbohydrate, protein, and fat metabolism,
and have anti-inflammatory properties.
 pH Potential hydrogen
Chemistry
• A measure of the acidity or alkalinity of a
solution, numerically equal to 7 for neutral
solutions, increasing with increasing
alkalinity and decreasing with increasing
acidity. The pH scale commonly in use
ranges from 0 to 14.
 Occupational Asthma
• Occupational asthma is defined as
asthma caused by exposure to an agent
encountered in the work environment.
• Occupations associated with a high risk
for occupational asthma include farming
and agricultural work, painting (including
spray painting), cleaning and plastic
manufacturing.
 Seasonal Asthma
• Seasonal asthma is usually
associated with allergic rhinitis.
• This type of asthma may occur
only intermittently, with the patient
being entirely asymptomatic
between seasons.
• Examples include birch, grass, and
ragweed pollens.
 Cough Variant Asthma

• These patients have chronic

cough as their principal symptom.
• Frequently this occurs at night;
• variability in lung function and
sputum eosinophil are
particularly important.
 Nocturnal asthma
• asthma often onset at night,
related to gastroesophageal
reflux and the regulate of the
nerve in day and night include
Pneumogastric nerves、
Sympathetic and
Parasympathetic nerve.
8 Differentiate Diagnosis
• Chronic asthmatic bronchitis
• Bronchial carcinoma
• Cardiac asthma
• Allergic pulmonary inflammation