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Bronchial Asthma!
Incidence:
Allergic asthma→ <18y
Non allergic asthma → >40y
RF For developing Asthma:
(+) Family history of Asthma or Allergies
Atopic dermatitis or Rhinitis or other allergies
Low socioeconomic

Factors initially triggers asthma or exacerbate an existing

condition:
Allergic asthma → Cardinal Features is P/O atopy (IgE mediated
Triad of Atopic Dermatitis + Allergic rhinitis + Asthma trigged by"
- Environmental allergens
- occupational allergens
Non allergic asthma → ACEs GVC
1. Aspirin → (aspirin-induced asthma)
2. Cold air
3. Exertion (exercise-induced asthma)
4. Stress
5. GERD
6. Viral URTI
7. Chronic sinusitis or rhinitis
Pathology → Product of Broncho-constriction + Inflammation →
Obstructive Lung Disease (OLD) → Air Trapping
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Chronic signs and symptoms:

I. Persistent dry cough that worsens at night
II. End-expiratory wheezes (Indicates Brooch-constriction and it’s
Suggesting OLD)
III. Chronic allergic rhinitis with atopy

Acute Asthma Attack (exacerbation):

Definition: Reversible episode of lower airway obstruction

Acute Severe Asthma

Inability to complete sentence in one breath

drowsy

>25

>110

PEFR is 35-50 of predicted

Clinical examination
Auscultation (characteristic findings are only present during acute
attacks)
Prolonged expiratory phase with wheezing
Hyperresonant sound with Percussion
Acute severe Asthma criteria (Kumar 2020)! :
1. Inability to complete sentence in one breath
2. RR>25/min
3. Pulse >=110 (pulsus paradoxusus is not useful since it present only
in 1/2 of patients)
4. PEFR = 35-50 of predicted
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Diagnosis:
P/O Clinical findings + PFTs (1st line)→ It will show OLD pattern
(FEV1/FVC is <70%) → Confirm with (SABA) → reversibility of OLD
pattern + ↑ in FEV1 of >12% (unlike COPD)
Methacholine challenge (broncho-provocation test)
• Second-line if PFT is non-diagnostic (normal)
• after inhalation of methacholine → FEV1 is ↓ ≥ 20% → This suggest
Bronchial hyper-sensitivity
CXR
-only in severe asthma to exclude Pneumonia, Pneumothorax
-in mild Asthma → Normal
-in Severe Asthma → Signs of Hyper inflated Chest
1-Low flattened diaphragm
2-Wide intercostal spaces
3-Barrel chest with reduce cardiac counter

Laboratory:
1-CBC: possibly eosinophilia
2-skin prick testing (SPT) or intra-dermal skin testing
3-In asthma triggered by infection: elevated inflammatory markers
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4-Pulse oximetry + ABG (if hypoxic)
5-In allergic asthma
↑ total IgE and allergen-specific IgE
Findings on ABG:
Initially: Respiratory alkalosis leading to type 1 Respiratory failure
Ultimately: Respiratory Acidosis leading to type 2 respiratory failure
Know: Difference between Type1 and 2 is the Co2 → CO2↑ in type 2
only
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Asthma severity classification:

Asthma Severity Daytime Sx Night Sx Fev1%

I ≤2d/w ≤2d/M >80% (Normal)

Mild Intermittent

II >2d/w 3-4/M >80% (Normal)

Mild Persistent

III Daily 1-2/W 60-80%

Moderate
Persistent

IV Through out the day Most Nights <60%

Severe
Persistent

V (Refractory) No Response to Rx → Oral Steroids

Differential of Asthma:

Genereal management:
Causal control:
1. Avoid triggers
2. Allergen immunotherapy in allergic asthma
3. Early Rx of infections in infection-triggered asthma
4. If GERD is suspected → PPI
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5. Self-monitoring with peak flow meter to measure peak expiratory
flow rate (PEFR)
6. Influenza + pneumococcal vaccines in all patients.
Know:! patients can avoid exacerbations with frequent PEFR
measurements → PEFR ↓ before Sx appear → indicates insufficient
medication regimen
Pharmaceutical management:
Reliever medications → taken as needed when symptoms are present
Controller medications→ control underlying inflammation of asthma →
Control Sx and Prevent Exacerbations

Longe term Pharmaceutical Management Based

on Steps (GINA guidelines 2020) NR = No response

Asthma symptoms Management→ Escalation/DeEsc

Strategy
asthma symptoms (≤2 times/week) Controller → as needed Low-dose ICS-Formeterol
Step 1 → Intermittent • IF NR "

Asthma symptoms or need for Controller → Daily Low dose ICS or

Step 2 reliever inhaler >2 times/week as step 1
→Mild Persistant • IF NR "

Step 3 asthma symptoms most days, Controller → Daily Low-dose ICS-LABA

nocturnal awakening ≥1 time/ • IF NR "
month, risk factors for
exacerbations
→ Moderate persistant
Severely uncontrolled asthma Controller → Daily Medium-dose ICS-LABA
Step 4
with ≥3 of following: • IF NR "
daytime symptoms >2 times/
Step 5 week Controller → Daily high-dose ICS-LABA
reliever needed for symptoms -Assess for possible add-on therapy (eg, tiotropium,
>2 times/week anti-IgE, anti-IL5/5R, anti-IL4R)
nocturnal awakening due to -May need short course of oral glucocorticoids
asthma
activity limitation due to asthma
→ Severe persistant
or An acute exacerbation

Preferred As needed Low-dose ICS-Formeterol

Reliever in
all steps
Main differences between SINA and
GINA guidelines is Step 1
SINA uses SABA as needed
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Asthma Exacerbation (Acute Asthma Attack)→ when Asthma

patient exposed to triggers and presenting with Active Sx
Management:
1-O2 → Make Sat >90%
2-Nebulizers (Nebz) → Ipratropium (SAMA) + Albuterol (SABA)
3-Steroids → Oral or IV depending on severity:
do PEFR → Status is it getting better or worse ⁉
-No O2 requirements + no wheezing + PEFR>70% → discharge with
oral prednisolone + daily medium dose ICS-LABA (step 4)
-↑O2 demeaned + ↓ Lung sounds + PEFR <70% → shift to ICU with
ventilator and IV Prednisolone + Continues Nebz
IF N.R to all of the above → Salvage Rx → Racemic or SC
Epinephrine or Mg sulfate
Know!
ICS = LTA in efficacy + MOA, so they are not used as combination
Exercise-induced asthma is best treated with an inhaled SABA prior
to exercise
LABA is not used alone in asthma due it ↑ risk of asthma
related death, So you must give with LABA + ICS
S/E of aminophilline → Cardiac arrest
NSAIDs are CI in asthma
Status asthmaticus
Definition: extreme asthma exacerbation that does not respond to initial
treatment with bronchodilators
Check this in any asthma pt who don't respond to medications:
Proper Use of the inhaler
Add spacer
Medication adherence
Acute severe Asthma (Kumar):
O2 + Nebz (if NR after 20min→ Repeat x3 → NR → IV aminophilines +
IV hydrocortisone for 2d then shifted to oral predsinilone
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Simplified asthma severity with management

Approach at the ER
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Bronchodilators:

They are either Antimuscarinic (parasympatholytic) or B2 agonist

Short Acting Beta Agonists Albuterol Terbutaline
(SABA)
Long Acting Beta Agonists Formoterol Salmeterol
(LABA)
Know: Albuterol = Salbutamol = Ventolin
Short Acting Muscarinic Ipratropium bromide
Antagonist (SAMA)
Long Acting Muscarinic Tiotropium bromide
Antagonist (LAMA)