Sarjan Final Project

“AN OVERVIEW OF ASTHMA & ITS TREATMENTS”
A REPORT OF PROJECT WORK
Submitted to
RAJIV GANDHI PROUDYOGIKI VISHWAVIDHALAYA, BHOPAL
In Partial Fulfillment of the Requirement for the Degree of
BACHELOR OF PHARMACY
2021-2022
SUPERVISED BY: SUBMITTED BY:

MRS. SADHANA MANGROLE MR. SARJAN MEENA
ASST. PROFESSOR B. PHARMACY VII SEMESTER
ENROLL. NO.0516PY181081
VIVEKANAND COLLEGE OF PHARMACY VIP CAMPUS, RATIBAD,

SIKANDARABAD BHOPAL, 462044
VIVEKANAND COLLEGE OF PHARMACY
VIP GAMPUS, RATIBAD, SIKANDARABAD BHOPAL, 462044
CERTIFICATE
This is to certify that Mr. SARJAN MEENA EnrollmentNo. 0516PY181081 a

student of B PHARMACY final year has satisfactorily submitted project on “AN
OVERVIEW OF ASTHMA AND ITS TREATMENT ”under my Supervision.
He has collected the literature very sincerely and methodically and his work his
authentic.
PROJECT INCHARGE
Mrs. ABHILASHA DELOURI
ASSO. PROFESSOR
FORWARDING LETTER
MR.SARJAN MEENA has completed his project work entitled “AN OVERVIEW OF
ASTHMA & ITS TREATMENTS”Under the Supervision and Guidence of Asst. Prof.
Mrs SADHANA MANGROLE fulfillment for the degree of Bachelor of Pharmacy.
The project is forwarded to RGPV Examiner for evaluation.
Dr. VIVEKANAND KATARE

(Principal)
DECLARATION
This is to certify that the dissertation word entitled “AN OVERIEW OF ASTHMA &
ITS TREATMENTS" for the award of carried by our laboratories and library under
the guidance and supervision of DR. VIVEKANAND KATARE.
It also declare that present work embody has not the basic award for any
degree or fellowship previously. The particular given in this Project are true to be
best knowledge.
Dr. VIVEKANAND KATARE SARJAN MEENA

(Principal) Enrollment. No. 0516PY181081
ACKNOWLEDGMENT
The completion of any project depends upon the co-operation, co-ordination

and combined efforts of several resources of knowledge, inspiration and energy.
Therefore I approach the important matter of project through these lines trying my
best to give full credit where it deserves.
I wish to express my deep sense of gratitude to my guide, Asst.Prof. Sadhana

Mangrole, VCP Faculty of Pharmacy for his valuable guidance and support for this
major project. I am heartily thankful to him for providing me his valuable
suggestions and remarks to complete these major projects. I think without his
guidance this thesis work could not be so successful.
I express my profound indebtedness to Dr. Vivekanand Katare, Principal VCP

Faculty of Pharmacy, Bhopal for providing all facilities required for making the
project successful It gives me an immense pleasure to thanks and expresses my
deep sense of gratitude to my Teaching staff of college, who has been an invarable
source of inspiration to me.
I am also thankful to my Non-Teaching Members, who always helped me in all

situations.
I express my sincere gratitude to my ever loving, affectionate, Parents, and my

friends who has been soils pillar of everlasting support and inspiration.
STUDENT
SARJAN MEENA
INDEX
S.NO TABLE OF CONTENT PAGE.NO.
1.
INTRODUCTION 02-04
2.
DEFINATION 05-06
3.
PATHOPHYSIOLOGY 07-08
4.
BRONCHOCONSTRICTION 09-11
5.
CAUSES 12-16
6.
DIAGNOSIS 17-20
7.
TREATMENT 21-23
8.
CONTROLLER MEDICATIONS 24-28
9.
CONCLUSION 29
10. REFERENCE 30-31

AN OVERVIEW OF ASTHMA & ITS TREATMENTS
ABSTRACT
Asthma is a disorder characterized by chronic airway inflammation, airway

hypersensitivity to a variety of stimuli, and airway obstruction. It is at least partially
reversible, either spontaneously or with treatment. Asthma affects 3–5% of the U.S.
population and is more common in children than in adults. Airway obstruction may
be due to smooth muscle spasms in the walls of smaller bronchi and bronchioles,
edema of the mucosa of the airways, increased mucus secretion, and/or damage to
the epithelium of the airway. Now a day’s so many marketed products are available
to treat the asthma and major step to cure this this disease patient should prevent
the exposure to antigen, reduction of bronchial inflammation and hyperactivity,
have to be used some medication to dilate the narrowed bronchi. This review article
was discussed about the pathophysiological approaches towards the asthma
management. Asthma is the most common respiratory disorder in Canada. Despite
significant improvement in the diagnosis and management of this disorder, the
majority of Canadians with asthma remain poorly controlled. In most patients,
however, control can be achieved through the use of avoidance measures and
appropriate pharmacological interventions. Inhaled corticosteroids (ICSs) represent
the standard of care for the majority of patients. Combination ICS/long-acting beta2-
agonists (LABA) inhalers are preferred for most adults who fail to achieve control
with ICS therapy. Allergen-specific immunotherapy represents a potentially disease-
modifying therapy for many patients with asthma, but should only be prescribed by
physicians with appropriate training in allergy. Regular monitoring of asthma
control, adherence to therapy and inhaler technique are also essential components
of asthma management. This article provides a review of current literature and
guidelines for the appropriate diagnosis and management of asthma.
Keywords: Pathophysiological approaches, symptoms, causes and treatment of
asthma.
1|Page
INTRODUCTION
 Individuals with asthma typically react to concentrations of agents too low to cause
symptoms in people without asthma. Sometimes the trigger is an allergen such as
pollen, house dust mites, molds, or a particular food.
 Other common triggers of asthma attacks are emotional upset, aspirin, sulfiting
agents (used in wine and beer and to keep greens fresh in salad bars), exercise, and
breathing cold air or cigarette smoke.
 In the early phase (acute) response, smooth muscle spasm is accompanied by

excessive secretion of mucus that may clog the bronchi and bronchioles and
worsen the attack.
 The late phase (chronic) response is characterized by inflammation, fibrosis,

edema, and necrosis (death) of bronchial epithelial cells. A host of mediator
chemicals, including leukotrienes, prostaglandins, thromboxane, plateletactivating
factor, and histamine take part.
 Symptoms include difficult breathing, coughing, wheezing, chest tightness,

tachycardia, fatigue, moist skin, and anxiety. An acute attack is treated by giving an
inhaled beta2-adrenergic agonist (albuterol) to help relax smooth muscle in the
bronchioles and open up the airways.
 However, long-term therapy of asthma strives to suppress the underlying

inflammation. The anti-inflammatory drugs that are used most often are inhaled
corticosteroids (glucocorticoids), cromolyn sodium), and leukotriene blockers)[1-
6]. Asthma is a chronic (long-term) lung disease that inflames and narrows the
airways.
 Asthma causes recurring periods of wheezing (a whistling sound when breathe),

chest tightness, shortness of breath, and coughing. The coughing often occurs at
night or early in the morning.
2|Page
 Asthma affects people of all ages, but it most often starts during childhood. In the
United States, more than 25 million people are known to have asthma. About 7
million of these people are children.
 To understand asthma, it helps to know how the airways work. The airways are
tubes that carry air into and out of lungs. People who have asthma have inflamed
airways.
 This makes them swollen and very sensitive.They tend to react strongly certain
inhaled substances. When the airways react, the muscles around them tighten. This
narrows the airways, causing less air to flow into the lungs. The swelling also can
worsen, making the airways even narrower. Cells in the airways might make more
mucus than usual.
 Mucus is a sticky, thick liquid that can further narrow the airways. This chain
reaction can result in asthma symptoms. Symptoms can happen each time the
airways are inflamed.
 Asthma remains the most common chronic respiratory disease in Canada, affecting
approximately 10% of the population .
 Although asthma is often believed to be a disorder localized to the lungs, current

evidence indicates that it may represent a component of systemic airway disease
involving the entire respiratory tract, and this is supported by the fact that asthma
frequently coexists with other atopic disorders, particularly allergic rhinitis.
 Despite significant improvements in the diagnosis and management of asthma

over the past decade, as well as the availability of comprehensive and widely-
accepted national and international clinical practice guidelines for the disease,
asthma control in Canada remains suboptimal.
 Results from the recent Reality of Asthma Control (TRAC) in Canada study suggest
that over 50% of Canadians with asthma have uncontrolled disease.
 Poor asthma control contributes to unnecessary morbidity, limitations to daily

activities and impairments in overall quality of life.
3|Page
 This article provides an overview of diagnostic and therapeutic guideline

recommendations from the Global Initiative for Asthma (GINA) and the Canadian
Thoracic Society and as well as a review of current literature related to the
pathophysiology, diagnosis, and appropriate treatment of asthma.
4|Page
DEFINITION
 Asthma is defined as a chronic inflammatory disease of the airways. The chronic

inflammation is associated with airway hyperresponsiveness (an exaggerated
airwaynarrowing response to triggers, such as allergens and exercise), that leads
to recurrent symptoms such as wheezing, dyspnea (shortness of breath), chest
tightness and coughing.
 Symptom episodes are generally associated with widespread, but variable,

airflow obstruction within the lungs that is usually reversible either
spontaneously or with appropriate asthma treatment
 Sometimes asthma symptoms are mild and go away on their own or after minimal
treatment with asthma medicine. Other times, symptoms continue to get worse.
 When symptoms get more intense and/or more symptoms occur, person is having
an asthma attack. Asthma attacks also are called flareups or exacerbations (eg-zas-
er-BA-shuns). Treating symptoms when first notice them is important.
 This will help prevent the symptoms from worsening and causing a severe asthma
attack. Severe asthma attacks may require emergency care, and they can be fatal.
 Outlook Asthma has no cure. Even when one feels fine, he/she still have the disease
and it can flare up at any time.
 However, with today's knowledge and treatments, most people who have asthma
are able to manage the disease. They have few, if any, symptoms.
 They can live normal, active lives and sleep through the night without interruption
from asthma. If one has asthma, he/she can take an active role in managing the
disease. For successful, thorough, and ongoing treatment, build strong
partnerships with doctor and other health care providers.
5|Page
Signs and symptoms

Asthma is characterized by recurrent episodes of wheezing, shortness of breath, chest
tightness, and coughing. Sputum may be produced from the lung by coughing but is
often hard to bring up.[22] During recovery from an asthma attack (exacerbation), it may
appear pus-like due to high levels of white blood cells called eosinophils.] Symptoms are
usually worse at night and in the early morning or in response to exercise or cold
air.[24] Some people with asthma rarely experience symptoms, usually in response to
triggers, whereas others may react frequently and readily and experience persistent
symptoms.
Associated conditions
A number of other health conditions occur more frequently in people with asthma,
including gastroesophageal reflux disease (GERD), rhinosinusitis, and obstructive sleep
apnea. Psychological disorders are also more common, with anxiety disorders occurring
in between 16–52% and mood disorders in 14–41% It is not known whether asthma
causes psychological problems or psychological problems lead to asthma. Current
asthma, but not former asthma, is associated with increased all-cause mortality, heart
disease mortality, and chronic lower respiratory tract disease mortality. Asthma,
particularly severe asthma, is strongly associated with development of chronic
obstructive pulmonary disease (COPD). Those with asthma, especially if it is poorly
controlled, are at increased risk for radiocontrast reactions.
Cavities occur more often in people with asthma. This may be related to the effect
of beta 2 agonists decreasing saliva. These medications may also increase the risk
of dental erosions.
6|Page
PATHOPHYSIOLOGY
 Asthma is associated with T helper cell type-2 (Th2) immune responses,

which are typical of other atopic conditions.
 Various allergic (e.g., dust mites, cockroach residue, furred animals, moulds,
pollens) and non-allergic (e.g., infections, tobacco smoke, cold air, exercise)
triggers produce a cascade of immune-mediated events leading to chronic
airway inflammation.
 Elevated levels of Th2 cells in the airways release specific cytokines,

including interleukin (IL)-4, IL-5, IL-9 and IL-13, that promote eosinophilic
inflammation and immunoglobulin E (IgE) production by mast cells.
 IgE production, in turn, triggers the release of inflammatory mediators, such

as histamine and cysteinyl leukotrienes, that cause bronchospasm
(contraction of the smooth muscle in the airways), edema (swelling) and
increased mucous secretion (mucous hypersecretion), which lead to the
characteristic symptoms of asthma .
 The mediators and cytokines released during the early phase of an immune
response to an inciting allergen, trigger a further inflammatory response
(late-phase asthmatic response) that leads to further airway inflammation
and bronchial hyperreactivity .
 Evidence suggests that there may be a genetic predisposition for the

development of asthma. A number of chromosomal regions associated with
asthma susceptibility have been identified, such as those related to the
production of IgE antibodies, expression of airway hyperresponsiveness, and
the production of inflammatory mediators.
 However, further study is required to determine specific genes involved in

asthma as well as the gene-environment interactions that may lead to
expression of the disease.
7|Page
 Asthma is a common pulmonary condition defined by chronic inflammation

of respiratory tubes, tightening of respiratory smooth muscle, and episodes
of bronchoconstriction.
 The Centers for Disease Control and Prevention estimate that 1 in 11

children and 1 in 12 adults have asthma in the United States of America.
 According to the World Health Organization, asthma affects 235 million

people worldwide.[There are two major categories of asthma: allergic and
non-allergic. The focus of this article will be allergic asthma. In both cases,
bronchoconstriction is prominent.
8|Page
BRONCHOCONSTRICTION
 During an asthma episode, inflamed airways react to environmental triggers such

as smoke, dust, or pollen. The airways narrow and produce excess mucus, making
it difficult to breathe. In essence, asthma is the result of an immune response in
the bronchial airways.
 The airways of asthma patients are "hypersensitive" to certain triggers, also
known as stimuli. (It is usually classified as type I hypersensitivity.) In response to
exposure to these triggers, the bronchi (large airways) contract into spasm (an
"asthma attack").
 Inflammation soon follows, leading to a further narrowing of the airways and
excessive mucus production, which leads to coughing and other breathing
difficulties. Bronchospasm may resolve spontaneously in 1–2 hours, or in about
50% of subjects, may become part of a 'late' response, where this initial insult is
follow 3–12 hours later with further bronchoconstriction and inflammation.
 The normal caliber of the bronchus is maintained by a balanced functioning of the

autonomic nervous system, which both operates reflexively.
The parasympathetic reflex loop consists of afferent nerve endings which
originate under the inner lining of the bronchus.
 Whenever these afferent nerve endings are stimulated (for example, by dust, cold
air or fumes) impulses travel to the brain-stem vagal center, then down the vagal
efferent pathway to again reach the bronchial small airways. Acetylcholine is
released from the efferent nerve endings
 . This acetylcholine results in the excessive formation of inositol 1,4,5-

trisphosphate (IP3) in bronchial smooth muscle cells which leads to muscle
shortening and this initiates bronchoconstriction.
9|Page
BRONCHIAL INFLAMMATION
 The mechanisms behind allergic asthma—i.e., asthma resulting from an immune

response to inhaled allergens—are the best understood of the causal factors.
 In both people with asthma and people who are free of the disease, inhaled
allergens that find their way to the inner airways are ingested by a type of cell
known as antigen-presenting cells, or APCs. APCs then "present" pieces of the
allergen to other immune system cells.
 In most people, these other immune cells (TH0 cells) "check" and usually ignore
the allergen molecules. In asthma patients, however, these cells transform into a
different type of cell (TH2), for reasons that are not well understood. A possible
reason could be the release of Interleukin-4 by Mast cells that induce
differentiation of naive helper T cells (Th0 cells) to Th2 cells.
 The resultant TH2 cells activate an important arm of the immune system, known
as the humoral immune system. The humoral immune system
produces antibodies against the inhaled allergen. Later, when a patient inhales
the same allergen, these antibodies "recognize" it and activate a humoral
response.
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 Inflammation results: chemicals are produced that cause the wall of the airway to
thicken, cells which produce scarring to proliferate and contribute to further
'airway remodeling', causes mucus producing cells to grow larger and produce
more and thicker mucus, and the cell-mediated arm of the immune system is
activated. Inflamed airways are more hyper-reactive, and will be more prone to
bronchospasm.
 The "hygiene hypothesis" postulates that an imbalance in the regulation of these
TH cell types in early life leads to a long-term domination of the cells involved in
allergic responses over those involved in fighting infection. The suggestion is that
for a child being exposed to microbes early in life, taking fewer antibiotics, living
in a large family, and growing up in the country stimulate the TH1 response and
reduce the odds of developing asthma.
 Asthma is associated with a procoagulant state in the bronchoalveolar space
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CAUSES
 Asthma is caused by a combination of complex and incompletely understood

environmental and genetic interactions. These influence both its severity and its
responsiveness to treatment.
 It is believed that the recent increased rates of asthma are due to

changing epigenetics (heritable factors other than those related to the DNA
sequence) and a changing living environment.
 Asthma that starts before the age of 12 years old is more likely due to genetic
influence, while onset after age 12 is more likely due to environmental influence.
 Asthma Is In One’s Lungs Whether He/she Feel It or Not. Asthma is a chronic

disease of the airways of the lungs. Unfortunately, asthma never goes away, but
the right treatment can help keep it under control.
 Asthma symptoms have two main causes [4-6], and both occur within the airways
of lungs: Airway Constriction This is the cause of asthma symptoms that one may
feel as a tightening in chest.
 The muscles around the airways of lungs squeeze together or tighten. This
tightening is often called "bronchoconstriction," and it can make it hard for one to
breathe.
 Many environmental factors have been associated with asthma's development
and exacerbation, including, allergens, air pollution, and other environmental
chemicals.
 Smoking during pregnancy and after delivery is associated with a greater risk of
asthma-like symptoms.[42] Low air quality from environmental factors such
as traffic pollution or high ozone levels has been associated with both asthma
development and increased asthma severity.
 Over half of cases in children in the United States occur in areas when air quality
is below the EPA standards. Low air quality is more common in low-income and
minority communities.
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 Exposure to indoor volatile organic compounds may be a trigger for

asthma; formaldehyde exposure, for example, has a positive association.
 The majority of the evidence does not support a causal role
between acetamin Phthalates in certain types of PVC are associated with asthma
in both children and adults.[48][49] While exposure to pesticides is linked to the
development of asthma, a cause and effect relationship has yet to be established.
 ophen (paracetamol) or antibiotic use and asthma. A 2014 systematic review
found that the association between acetaminophen use and asthma disappeared
when respiratory infections were taken into account.
 Acetaminophen use by a mother during pregnancy is also associated with an
increased risk of the child developing asthma. Maternal psychological
stress during pregnancy is a risk factor for the child to develop asthma.
 Asthma is associated with exposure to indoor allergens.[57] Common indoor
allergens include dust mites, cockroaches, animal dander (fragments of fur or
feathers), and mold.
 Efforts to decrease dust mites have been found to be ineffective on symptoms in
sensitized subjects. Weak evidence suggests that efforts to decrease mold by
repairing buildings may help improve asthma symptoms in adults.
 Certain viral respiratory infections, such as respiratory syncytial
virus and rhinovirus,[20] may increase the risk of developing asthma when
acquired as young children.[63] Certain other infections, however, may decrease
the risk.
Hygiene hypothesis
 The hygiene hypothesis attempts to explain the increased rates of asthma

worldwide as a direct and unintended result of reduced exposure, during
childhood, to non-pathogenic bacteria and viruses.
 It has been proposed that the reduced exposure to bacteria and viruses is due, in
part, to increased cleanliness and decreased family size in modern societies.
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 Exposure to bacterial endotoxin in early childhood may prevent the development

of asthma, but exposure at an older age may provoke
bronchoconstriction. Evidence supporting the hygiene hypothesis includes
[67]
lower rates of asthma on farms and in households with pets.

 Use of antibiotics in early life has been linked to the development of asthma.
 Also, delivery via caesarean section is associated with an increased risk
(estimated at 20–80%) of asthma – this increased risk is attributed to the lack of
healthy bacterial colonization that the newborn would have acquired from
passage through the birth canal.
 There is a link between asthma and the degree of affluence which may be related
to the hygiene hypothesis as less affluent individuals often have more exposure to
bacteria and viruses
Genetic
 Family history is a risk factor for asthma, with many different genes being
implicated.] If one identical twin is affected, the probability of the other having the
disease is approximately 25%.
 By the end of 2005, 25 genes had been associated with asthma in six or more
separate populations, including GSTM1, IL10, CTLA-
4, SPINK5, LTC4S, IL4R and ADAM33, among others.
 Many of these genes are related to the immune system or modulating

inflammation. Even among this list of genes supported by highly replicated
studies, results have not been consistent among all populations tested.[74] In 2006
over 100 genes were associated with asthma in one genetic association study
alone; more continue to be found.
 Some genetic variants may only cause asthma when they are combined with
specific environmental exposures.
 An example is a specific single nucleotide polymorphism in the CD14 region and

exposure to endotoxin (a bacterial product). Endotoxin exposure can come from
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several environmental sources including tobacco smoke, dogs, and farms. Risk for
asthma, then, is determined by both a person's genetics and the level of endotoxin
exposure.
Medical conditions
 A triad of atopic eczema, allergic rhinitis and asthma is called atopy.[76] The
strongest risk factor for developing asthma is a history of atopic disease with
asthma occurring at a much greater rate in those who have either eczema or hay
fever.
 Asthma has been associated with eosinophilic granulomatosis with
polyangiitis (formerly known as Churg–Strauss syndrome), an autoimmune
disease and vasculitis Individuals with certain types of urticaria may also
experience symptoms of asthma.
 There is a correlation between obesity and the risk of asthma with both having
increased in recent years.[79][80] Several factors may be at play including decreased
respiratory function due to a buildup of fat and the fact that adipose tissue leads
to a pro-inflammatory state.[81]
 Beta blocker medications such as propranolol can trigger asthma in those who
are susceptible. Cardioselective beta-blockers, however, appear safe in those with
mild or moderate disease.
 Other medications that can cause problems in asthmatics are angiotensin-
converting enzyme inhibitors, aspirin, and NSAIDs.[85] Use of acid suppressing
medication (proton pump inhibitors and H2 blockers) during pregnancy is
associated with an increased risk of asthma in the child.
Exacerbation
 Some individuals will have stable asthma for weeks or months and then suddenly
develop an episode of acute asthma. Different individuals react to various factors
in different ways.[87] Most individuals can develop severe exacerbation from a
number of triggering agents.
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 Home factors that can lead to exacerbation of asthma include dust,

animal dander (especially cat and dog hair), cockroach allergens and mold.
Perfumes are a common cause of acute attacks in women and children.
 Both viral and bacterial infections of the upper respiratory tract can worsen the
disease.[87] Psychological stress may worsen symptoms – it is thought that stress
alters the immune system and thus increases the airway inflammatory response
to allergens and irritants.
 Asthma exacerbations in school‐aged children peak in autumn, shortly after
children return to school. This might reflect a combination of factors, including
poor treatment adherence, increased allergen and viral exposure, and altered
immune tolerance. There is limited evidence to guide possible approaches to
reducing autumn exacerbations, but while costly, seasonal omalizumab treatment
from four to six weeks before school return may reduce autumn asthma
exacerbations
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DIAGNOSIS
 The diagnosis of asthma involves a thorough medical history, physical examination,

and objective assessments of lung function (spirometry preferred) to confirm the
diagnosis.
 Bronchoprovocation challenge testing and assessing for markers of airway

inflammation may also be helpful for diagnosing the disease, particularly when
objective measurements of lung function are normal despite the presence of asthma
symptoms
 Medical history The diagnosis of asthma should be suspected in patients with

recurrent cough, wheeze, chest tightness and shortness of breath.
 Symptoms that are variable, occur upon exposure to allergens or irritants, that
worsen at night, and that respond to appropriate asthma therapy are strongly
suggestive of asthma .
 Alternative causes of suspected asthma symptoms should be excluded, such as

chronic obstructive pulmonary disease (COPD), bronchitis, chronic sinusitis,
gastroesophageal reflux disease, recurrent respiratory infections, and heart disease.
 A positive family history of asthma or other atopic diseases and/or a personal

history of atopic disorders, particularly allergic rhinitis, can also be helpful in
identifying patients with asthma.
 During the history, it is also important to examine for possible triggers of asthma
symptoms, such as dust mites, cockroaches, animal dander, moulds, pollens,
exercise, and exposure to tobacco smoke or cold air. Exposure to agents
encountered in the work environment can also cause asthma.
 If workrelated asthma is suspected, details of work exposures and improvements in

asthma symptoms during holidays should be explored. It is also important to assess
for comorbidities that can aggravate asthma symptoms, such as allergic rhinitis,
sinusitis, obstructive sleep apnea and gastroesophageal reflux disease.
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 The diagnosis of asthma in young children is often more difficult since episodic
wheezing and cough are common in this patient population and spirometry is
unreliable in patients under 6 years of age.
 A useful method of confirming the diagnosis in young children is a trial of treatment

with short-acting bronchodilators and inhaled corticosteroids (ICSs).
 Marked clinical improvement during treatment and deterioration upon cessation of

therapy supports a diagnosis of asthma .
 Physical examination Given the variability of asthma symptoms, the physical

examination of patients with suspected asthma is often unremarkable. Physical
findings are usually only evident if the patient is symptomatic.
 Therefore, the absence of physical findings does not rule out a diagnosis of asthma.
The most common abnormal physical finding is wheezing on auscultation, which
confirms the presence of airflow limitation.
 Physicians should also examine the upper respiratory tract and skin for signs of
concurrent atopic conditions such as allergic rhinitis or dermatitis .
 Objective measurements of lung function Spirometry is the preferred objective

measure to assess for reversible airway obstruction (i.e., rapid improvement in lung
function after inhalation of a rapid-acting bronchodilator) and to confirm a diagnosis
of asthma.
 It is recommended for all patients over 6 years of age who are able to undergo lung
function testing [4,6]. Spirometry must be performed according to proper protocols.
It is commonly performed in pulmonary function laboratories, but can also be
performed in primary-care offices.
 During spirometry, the patient is instructed to take the deepest breath possible and
then to exhale as hard and as fully as possible into the mouthpiece of the spirometer.
Spirometry measures the forced vital capacity (FVC, the maximum volume of air that
can be exhaled) and the forced expiratory volume in 1 second (FEV1).
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 The ratio of FEV1 to FVC provides a measure of airflow obstruction. A diagnosis of

asthma is confirmed when there is: an improvement in FEV1 of at least 12% and at
least 200 mL 15–20 minutes after administration of an inhaled rapid-acting
bronchodilator, or an improvement in FEV1 of at least 20% and at least 200 mL after
2 weeks of treatment with an anti-inflammatory agent.
 In the general population, the FEV1/FVC ratio is usually greater than 0.80 (and
possibly greater than 0.90 in children) and, therefore, any values less than these
suggest airflow limitation and also support a diagnosis of asthma.
 Because of the variability of asthma symptoms, patients will not exhibit reversible
airway obstruction at every visit. Therefore, to increase sensitivity, spirometry
should be repeated, particularly when patients are symptomatic .
 Peak expiratory flow (PEF) monitoring is an acceptable alternative when

spirometry is not available, and can also be useful for diagnosing occupational
asthma and/ or monitoring response to asthma treatments. PEF is usually measured
in the morning and in the evening.
 A diurnal variation in PEF of more than 20% or an improvement of at least 60 L/min

or at least 20% after inhalation of a rapid-acting bronchodilator suggests asthma .
 Although simpler to perform than spirometry, PEF is not as reliable. Therefore, as

mentioned earlier, spirometry is the preferred method of documenting airflow
limitation and confirming the diagnosis of asthma.
 Challenge testing When lung function tests are normal, but symptoms suggest
asthma, measurements of airway responsiveness using direct airway challenges to
inhaled bronchoconstrictor stimuli (e.g., methacholine or histamine) or indirect
challenges with mannitol or exercise may help confirm a diagnosis of asthma.
 Challenge testing should be conducted in accordance with strict protocols in a

laboratory or other facility equipped to manage acute bronchospasms. Testing
involves the patient inhaling increasing doses or concentrations of a stimulus until a
given level of bronchoconstriction is achieved, typically a 20% fall in FEV1.
19 | P a g e
 An inhaled rapid-acting bronchodilator is then provided to reverse the obstruction.

Test results are usually expressed as the dose or concentration of the provoking
agent that causes the FEV1 to drop by 20% (the PD20 or PC20, respectively).
 For methacholine, a PC20 value less than 8 mg/mL is considered a positive result
indicative of airway hyperreactivity, and supports a diagnosis of asthma.
 However, positive challenge tests are not specific to asthma and may occur with
other conditions such as allergic rhinitis and COPD. Therefore, challenge testing may
be most useful for ruling out asthma.
 A negative test result in a symptomatic patient not receiving anti-inflammatory

therapy is highly sensitive for ruling out the disease .
 Challenge testing is contraindicated in patients with FEV1 values less than 60-70%
of the normal predicted value (since bronchoprovocation could cause significant
bronchospasms), in patients with uncontrolled hypertension or in those who
recently experienced a stroke or myocardial infarction.
Non-invasive markers of airway inflammation
 The measurement of inflammatory markers such as sputum eosinophilia (amount of

eosinophils in the sputum) or levels of exhaled nitric oxide (a gaseous molecule
produced by some cells during an inflammatory response) can also be useful for
diagnosing asthma.
 Evidence suggests that exhaled nitric oxide levels may be better able to identify
asthmatic patients than basic lung function testing, and may also be useful for
monitoring patient response to asthma therapy.
 Although these tests have been studied in the diagnosis and monitoring of asthma,
they are not yet widely used in Canada. With further clinical evidence and use, these
markers of airway inflammation will likely become more commonly available.
 Allergy skin testing is also recommended to determine the allergic status of the
patient and to identify possible asthma triggers. Testing is typically performed using
the allergens relevant to the patient’s geographic region.
20 | P a g e
TREATMENT
 The primary goal of asthma management is to achieve and maintain control of the
disease in order to prevent exacerbations (abrupt and/or progressive worsening of
asthma symptoms that often require immediate medical attention and/or the use of
oral steroid therapy) and reduce the risk of morbidity and mortality.
 The level of asthma control should be assessed at each visit using the criteria , and
treatment should be tailored to achieve control. In most asthma patients, control can
be achieved through the use of both avoidance measures and pharmacological
interventions.
 The pharmacologic agents commonly used for the treatment of asthma can be
classified as controllers (medications taken daily on a long-term basis that achieve
control primarily through anti-inflammatory effects) and relievers (medications
used on an as-needed basis for quick relief of bronchoconstriction and symptoms)
 Controller medications include ICSs, leukotriene receptor antagonists (LTRAs),

long-acting beta2-agonists (LABAs) in combination with an ICS, and anti-IgE
therapy. Reliever medications include rapid-acting inhaled beta2-agonists and
inhaled anticholinergics.
 Allergen-specific immunotherapy may also be considered in most patients with

allergic asthma, but must be prescribed by physicians who are adequately trained in
the treatment of allergies.
 Systemic corticosteroid therapy may also be required for the management of acute
asthma exacerbations. A simplified, stepwise algorithm for the treatment of asthma
is provided in.
 When asthma control has been achieved, ongoing monitoring is essential to

establish the minimum maintenance doses required to maintain control.
 However, because asthma is a variable disease, treatment may need to be adjusted

periodically in response to loss of control (as indicated by failure to meet the control
criteria in Table 2) [4]. It is also imperative that all asthma patients be empowered
to take an active role in the management of their disease.
21 | P a g e
 This can be accomplished by providing patients with a personalized written action

plan for disease management and by educating the patient about the nature of the
disease, the role of medications, the importance of adhering to controller therapy,
and the appropriate use of inhaler devices
Avoidance measures
 Avoidance of relevant allergens/irritants is an important component of asthma

management.
 Patients allergic to house dust mites should be instructed to use

allergenimpermeable covers for bedding and to keep the relative humidity in the
home below 50% (to inhibit mite growth).
 Pollen exposure can be reduced by keeping windows closed, using an air

conditioner, and limiting the amount of time spent outdoors during peak pollen
seasons. For patients allergic to animal dander, removal of the animal from the home
is recommended and usually results in a significant reduction in symptoms within 4-
6 months.
 However, compliance with this recommendation is poor and, therefore, the use of
highefficiency particulate air (HEPA) filters and restricting the animal from the
bedroom or to the outdoors may be needed to attempt to decrease allergen levels.
 Measures for reducing exposure to mould allergens include cleaning with

fungicides, de-humidification to less than 50%, and HEPA filtration. Cigarette
smoking and exposure to second-hand tobacco smoke should also be avoided .
 Since these avoidance strategies can be labour-intensive, patient adherence is

usually suboptimal. Frequent reassessments, encouragement and empowerment by
the treating physician are often required to help promote adherence to these
strategies.
 Furthermore, patients should be advised to use a combination of avoidance

measures for optimal results, since single-strategy interventions have demonstrated
no measurable benefits in asthma control.
22 | P a g e
Reliever medications
 Inhaled rapid-acting beta2-agonists are the preferred reliever medications for the
treatment of acute symptoms, and should be prescribed to all patients with asthma.
 In Canada, several short-acting beta2-agonists (SABAs; e.g., salbutamol, terbutaline)

and one LABA (formoterol) are approved for this indication. SABAs should only be
taken on an as needed basis for symptom relief. Increased use (i.e., 3 or more times
per week) indicates worsening control and signals the need to reassess treatment to
achieve control of symptoms.
 Unlike other LABAs, formoterol has a rapid onset of action and, therefore, can be
used for acute symptom relief. However, given that LABA monotherapy has been
associated with an increased risk of asthma-related morbidity and mortality,
formoterol should only be used as a reliever in patients 12 years of age or older who
are on regular controller therapy with an ICS [4,6,7].
 Short-acting anticholinergic bronchodilators, such as ipratropium bromide, may

also be used as reliever therapy.
 However, these agents appear to be less effective than inhaled rapid-acting beta2-
agonists and, therefore, should be reserved as second-line therapy for patients who
are unable to use SABAs
 . They may also be used in addition to SABAs in patients experiencing moderate to

severe asthma exacerbations. Furthermore, chronic, short-acting anticholinergic
bronchodilator therapy is not recommended for use in children.
23 | P a g e
CONTROLLER MEDICATIONS
Inhaled corticosteroids (ICSs)
 ICSs are the most effective anti-inflammatory medications available for the
treatment of asthma and represent the mainstay of therapy for most patients with
thedisease.
 Low-dose ICS monotherapy is recommended as first-line maintenance therapy for

most children and adults with asthma. Regular ICS use has been shown to reduce
symptoms and exacerbations, and improve lung function and quality of life.
 However, ICSs do not “cure” asthma, and symptoms tend to recur within weeks to
months of ICS discontinuation. Therefore, most patients will require long-term, if
not life-long, ICS treatment.
 Since ICSs are highly effective when used optimally, factors other than treatment
efficacy need to be considered if ICS therapy is unsuccessful in achieving asthma
control.
 These factors include: misdiagnosis of the disease, poor adherence to ICS therapy,
improper inhaler technique, or the presence of other comorbidities.
 If, after addressing such factors, patients fail to achieve control with low-to-
moderate ICS doses, then treatment should be modified. For most children, ICS dose
escalation (to a moderate dose) is the preferred approach to achieve control, while
the addition of another class of medications (usually a LABA) is recommended for
patients over 12 years of age.
 The most common local adverse events associated with ICS therapy are
oropharyngeal candidiasis (also known as oral thrush) and dysphonia (hoarseness,
difficulty speaking).
 Rinsing and expectorating (spitting) after each inhalation and/or the use of a spacer
device can help reduce the risk of these side effects. Systemic adverse effects with
ICS therapy are rare, but may include adrenal suppression, changes in bone density,
cataracts, glaucoma and growth retardation.
24 | P a g e
Leukotriene receptor antagonists (LTRAs)
 The LTRAs montelukast and zafirlukast are also effective for the treatment of
asthma and are generally considered to be safe and well tolerated.
 However, because these agents are less effective than ICS treatment when used as
monotherapy, they are usually reserved for patients who are unwilling or unable to
use ICSs.
 LTRAs can also be used as add-on therapy if asthma is uncontrolled despite the use
of low-to-moderate dose ICS therapy. It is important to note, however, that LTRAs
are considered to be less effective than LABAs as add-on therapy in adults .
 In children, however, the data are less clear and, therefore, the child’s symptoms
and the presence of comorbidities may help direct treatment. For example, if a child
with asthma also has allergic rhinitis, the addition of montelukast should be
considered.
 If, however, the child has persistent airway obstruction, the addition of a LABA may
be preferred.
 Combination ICS/LABA inhalers As mentioned earlier, LABA monotherapy is not

recommended in patients with asthma as it does not impact airway inflammation
and is associated with an increased risk of morbidity and mortality.
 LABAs are only recommended when used in combination with ICS therapy. The
combination of a LABA and ICS has been shown to be highly effective in reducing
asthma symptoms and exacerbations, and is the preferred treatment option in
adolescents or adults whose asthma is inadequately controlled on low-dose ICS
therapy, or in children over 6 years of age who are uncontrolled on moderate ICS
doses.
 Although there is no apparent difference in efficacy between ICSs and LABAs given
in the same or in separate inhalers, combination ICS/ LABA inhalers are preferred
because they preclude use of the LABA without an ICS, are more convenient and may
enhance patient adherence.
25 | P a g e
 Three combination ICS/LABA inhalers are available in Canada: salmeterol/

fluticasone (Advair), budesonide/formoterol (Symbicort) and
mometasone/formoterol (Zenhale). Combination budesonide/formoterol has
recently been approved for use in Canada as a single inhaler for both daily
maintenance (controller) and reliever therapy in individuals 12 years of age and
older.
 It should only be used in patients whose asthma is not adequately controlled with
low-tomoderate ICS doses or whose disease severity warrants treatment with
combination therapy.
. Theophylline
 Theophylline is an oral bronchodilator with modest anti-inflammatory effects. Given

its narrow therapeutic window and frequent adverse events (e.g., gastrointestinal
symptoms, loose stools, seizures, cardiac arrhythmias, nausea and vomiting), its use
is generally reserved for patients whose asthma is uncontrolled despite an adequate
trial of ICS, LABAs and/or LTRAs.
Anti-IgE therapy
 The anti-IgE monoclonal antibody, omalizumab, has been shown to reduce the
frequency of asthma exacerbations by approximately 50%. The drug is administered
subcutaneously once every 2-4 weeks and is approved in Canada for the treatment
of moderate to severe, persistent allergic asthma in patients 12 years of age or older.
 At present, omalizumab is reserved for patients with difficult to control asthma who
have documented allergies and whose asthma symptoms remain uncontrolled
despite ICS therapy.
 It is important to note that long-term compliance with controller therapy is poor

because patients tend to stop therapy when their symptoms subside.
 Therefore, regular follow-up visits are important to help promote treatment

adherence.
26 | P a g e
Systemic corticosteroids
 Systemic corticosteroids, such as oral prednisone, are generally used for the acute
treatment of moderate to severe asthma exacerbations. While chronic systemic
corticosteroid therapy may also be effective for the management of difficult to
control asthma, prolonged use of oral steroids are associated with well-known and
potentially serious adverse effects and, therefore, their long-term use should be
avoided if at all possible.
 Adverse events with short-term, high-dose oral prednisone are uncommon, but may
include: reversible abnormalities in glucose metabolism, increased appetite, edema,
weight gain, rounding of the face, mood alterations, hypertension, peptic ulcers and
avascular necrosis.
Allergen-specific immunotherapy
 Allergen-specific immunotherapy involves the subcutaneous administration of

gradually increasing quantities of the patient’s relevant allergens until a dose is
reached that is effective in inducing immunologic tolerance to the allergen.
27 | P a g e
 Although it has been widely used to treat allergic asthma, it is not universally
accepted by all clinical practice guideline committees due to the potential for serious
anaphylactic reactions with this form of therapy.
 A Cochrane review of 75 randomized controlled trials examining the use of allergen-

specific immunotherapy in asthma management confirmed its efficacy in reducing
asthma symptom scores and medication requirements, and improving airway
hyperresponsiveness.
 Similar benefits have been noted with sublingual immunotherapy, which is

expected to be approved in Canada in the near future. Evidence also suggests that
allergen-specific immunotherapy may prevent the onset of asthma in atopic
individuals.
 At present, allergen-specific immunotherapy should be considered on a case-by-

case basis. It can be used prior to a trial of ICS therapy in patients with very mild
allergic asthma and concomitant allergic rhinitis and as add-on therapy in patients
using ICSs alone.
 Allergen-specific immunotherapy may also be considered in patients using

combination inhalers, ICS/LTRAs and/or omalizumab if asthma symptoms are
controlled.
 Since allergen-specific immunotherapy carries the risk of anaphylactic reactions, it

should only be prescribed by physicians who are adequately trained in the
treatment of allergy.
 The injections must be given in clinics that are equipped to manage possible life-
threatening anaphylaxis where a physician is present. Furthermore, to reduce the
risk of serious reactions, asthma must be controlled and the FEV1 > 70% of
predicted at the time of each immunotherapy injection
28 | P a g e
CONCLUSION
Asthma is the most common respiratory disorder in Canada, and contributes to

significant morbidity and mortality. A diagnosis of asthma should be suspected in
patients with recurrent cough, wheeze, chest tightness and dyspnea, and should be
confirmed using objective measures of lung function (spirometry preferred). Allergy
testing is also recommended to identify possible triggers of asthma symptoms. In
most patients, asthma control can be achieved through the use of avoidance measures
and appropriate pharmacological interventions. ICSs represent the standard of care
for the majority of asthma patients. For those who fail to achieve control with low-to-
moderate ICS doses, combination therapy with a LABA and ICS is the preferred
treatment choice in most adults. LTRAs can also be used as add-on therapy if asthma
is uncontrolled despite the use of low-to-moderate dose ICS therapy, particularly in
patients with concurrent allergic rhinitis. Anti-IgE therapy may be useful in select
cases of difficult to control asthma. Allergen-specific immunotherapy is a potentially
disease-modifying therapy, but should only be prescribed by physicians with
appropriate training in allergy. All patients with asthma should have regular follow-up
visits during which criteria for asthma control, adherence to therapy and proper
inhaler technique should be reviewed
29 | P a g e
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“AN OVERVIEW OF ASTHMA & ITS TREATMENTS”

A REPORT OF PROJECT WORK

SUPERVISED BY: SUBMITTED BY:

VIVEKANAND COLLEGE OF PHARMACY VIP CAMPUS, RATIBAD,

This is to certify that Mr. SARJAN MEENA EnrollmentNo. 0516PY181081 a

The project is forwarded to RGPV Examiner for evaluation.

Dr. VIVEKANAND KATARE

Dr. VIVEKANAND KATARE SARJAN MEENA

The completion of any project depends upon the co-operation, co-ordination

I wish to express my deep sense of gratitude to my guide, Asst.Prof. Sadhana

I express my profound indebtedness to Dr. Vivekanand Katare, Principal VCP

I am also thankful to my Non-Teaching Members, who always helped me in all

I express my sincere gratitude to my ever loving, affectionate, Parents, and my

S.NO TABLE OF CONTENT PAGE.NO.

10. REFERENCE 30-31

Asthma is a disorder characterized by chronic airway inflammation, airway

 In the early phase (acute) response, smooth muscle spasm is accompanied by

 The late phase (chronic) response is characterized by inflammation, fibrosis,

 Symptoms include difficult breathing, coughing, wheezing, chest tightness,

 However, long-term therapy of asthma strives to suppress the underlying

 Asthma causes recurring periods of wheezing (a whistling sound when breathe),

 Although asthma is often believed to be a disorder localized to the lungs, current

 Despite significant improvements in the diagnosis and management of asthma

 Poor asthma control contributes to unnecessary morbidity, limitations to daily

 This article provides an overview of diagnostic and therapeutic guideline

 Asthma is defined as a chronic inflammatory disease of the airways. The chronic

 Symptom episodes are generally associated with widespread, but variable,

Signs and symptoms

 Asthma is associated with T helper cell type-2 (Th2) immune responses,

 Elevated levels of Th2 cells in the airways release specific cytokines,

 IgE production, in turn, triggers the release of inflammatory mediators, such

 Evidence suggests that there may be a genetic predisposition for the

 However, further study is required to determine specific genes involved in

 Asthma is a common pulmonary condition defined by chronic inflammation

 The Centers for Disease Control and Prevention estimate that 1 in 11

 According to the World Health Organization, asthma affects 235 million

 During an asthma episode, inflamed airways react to environmental triggers such

 The normal caliber of the bronchus is maintained by a balanced functioning of the

 . This acetylcholine results in the excessive formation of inositol 1,4,5-

 The mechanisms behind allergic asthma—i.e., asthma resulting from an immune

 Asthma is caused by a combination of complex and incompletely understood

 It is believed that the recent increased rates of asthma are due to

 Asthma Is In One’s Lungs Whether He/she Feel It or Not. Asthma is a chronic

 Exposure to indoor volatile organic compounds may be a trigger for

 The hygiene hypothesis attempts to explain the increased rates of asthma

 Exposure to bacterial endotoxin in early childhood may prevent the development

lower rates of asthma on farms and in households with pets.

 Many of these genes are related to the immune system or modulating

 An example is a specific single nucleotide polymorphism in the CD14 region and

 Home factors that can lead to exacerbation of asthma include dust,

 The diagnosis of asthma involves a thorough medical history, physical examination,

 Bronchoprovocation challenge testing and assessing for markers of airway

 Medical history The diagnosis of asthma should be suspected in patients with

 Alternative causes of suspected asthma symptoms should be excluded, such as

 A positive family history of asthma or other atopic diseases and/or a personal

 If workrelated asthma is suspected, details of work exposures and improvements in

 A useful method of confirming the diagnosis in young children is a trial of treatment

 Marked clinical improvement during treatment and deterioration upon cessation of

 Physical examination Given the variability of asthma symptoms, the physical

 Objective measurements of lung function Spirometry is the preferred objective

 The ratio of FEV1 to FVC provides a measure of airflow obstruction. A diagnosis of

 Peak expiratory flow (PEF) monitoring is an acceptable alternative when

 A diurnal variation in PEF of more than 20% or an improvement of at least 60 L/min

 Although simpler to perform than spirometry, PEF is not as reliable. Therefore, as