Bronchial Asthma

Hanan El tokhy, MD, Faculty of Medicine for Girls, Al-Azhar University

 Normal Bronchial Tubes The air we breathe in through our nose and mouth passes through the vocal cords (larynx) and into the windpipe (trachea). The air then enters the lungs by way of two large air passages (bronchi), one for each lung. The bronchi divide within each lung into progressively smaller air tubes (bronchioles), just like branches of an inverted tree. Inhaled air is brought through these airways to the millions of tiny air sacs (alveoli) that are contained in the lungs. Oxygen (O2) passes from the air sacs into the bloodstream through numerous tiny blood vessels called capillaries. Similarly, the body's waste product, carbon dioxide (CO2), is returned to the air sacs and then eliminated upon each exhalation.

Bronchial Asthma
A chronic inflammatory disease of the airways, the Inflammation is accompanied by swelling of the

mucous membrane in the bronchi, production

of viscous secretions and smooth muscle spasm narrowing the airways that causes "attacks" of coughing, wheezing, shortness of breath, and chest tightness.

So asthma characterized by: Reversible airway constriction Airway inflammation and Airway hyper-responsiveness to a wide variety of stimuli (antigens)

What is the Pathophysiology?

Exposure to trigger Factors Mast cell & Inflammatory cells T-lymphocytes, Mediators: histamine, prostaglandin, leukotrienes, and cytokines. Hypertrophy of the smooth muscles, thickening of the basement membrane airway smooth muscles contraction (Bronchoconstriction) & Airway wall swelling (mucosal edema)

What are the Triggering Factors?

1) Allergic: Domestic dust mites Air pollution Tobacco smoke Cockroach Animal with fur Pollen Respiratory (viral) infections Chemical irritants 2) Non- allergic Strong emotional expressions Drugs ( aspirin, beta blockers)

Some trigger factors

 In susceptible individuals , inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night/early morning. These episodes are associated with variable airflow obstruction often reversible spontaneously/treatment

different mechanism
Drugs ( aspirin, non- steroidal antiinflammatory drugs and beta blockers as propranolol) have different mechanism by which they produce bronchospasm : they block the beta cells in the bronchial tree ( that responsible for bronchial dilatation) leading to the occurrence of the bronchospasm.

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SIGNS AND SYMPTOMS

Dyspnea, Shortness of breath Tightness of chest Wheezing Excessive coughing or a cough that keeps you awake at night, Patient may dvelop cyanosis in sevre asthma

Diagnosis of bronchial asthma

Consultation skill Relevant History, Symptom, history of allergic disease &Family history American Thoracic Society : 4 out of 5 1. Wheezing with colds 2. Wheezing apart from colds. 3. Dyspnea associated with wheeze. 4. Wheeze after exertion 5. Persistent cough Exclusion of other medical condition

Do you need to do investigation? Why ? There is no specific test for bronchial asthma, = no specific laboratory test for diagnosis of asthma. Pulmonary function test just: Tells us that there is obstructive disease not necessary to be B.asthma. Testing the response of patients to bronchodilators and or steroids

How to manage Bronchial Asthma?

Educate patients to develop a partnership in asthma care

Avoid exposure to trigger factors

Assess and monitor asthma severity Establish individual medication plans for long term management in children and adults

CLASSIFY ASTHMA SEVERITY

Mild intermittent Asthma (step1) Mild persistent Asthma (step2) Moderate persistent Asthma (step3) Severe persistent Asthma (step4)

Medication plans
Medications for relieving the symptoms (bronchodilators). Medications for preventing the attacks ( anti-inflammatory drugs)

Step 1-Quick relief medications Short acting bronchodilators -beta2-agonists relief of acute symptoms used by inhalation as needed to relief occasional minor symptoms.

If the patient is using those bronchodilators more than daily, shift to step 2

once

Step 2
The same medications in step 1 +regular inhaled anti- inflammatory drugs and low dose inhaled steroids). If the condition not improved step 3 shift to

Step 3

Medications in step 2 + High dose inhaled steroids or Low dose inhaled steroids + Long-acting inhaled beta2-agonists used concomitantly with anti-inflammatory drugs for long-term symptom control especially nocturnal symptoms

Step 4
Step 3 plus regular steroid therapy (tablets) as a single dose in the morning