Reading Assignment: Asthma and GINA guidelines

Asthma
 Characterized by airflow obstruction that varies markedly, both spontaneously and with treatment
 Narrowing of the airways is usually reversible, but in some chronic asthmatics, there may be an
element of irreversible airflow obstruction

Risk Factors

Pathophysiology
 Airway mucosa is infiltrated with activated eosinophils and T lymphocytes, and there is
activation of mucosal mast cells

 Degree of inflammation is poorly related to disease severity and may even be found in atopic patients
without asthma symptoms

 Inflammation is usually reduced by treatment with ICS

 There are also structural changes in the airways (often termed remodeling)

o A characteristic finding is thickening of the basement membrane due to subepithelial

collagen depositio

 Also found in patients with eosinophilic bronchitis presenting as cough who do not have
asthma and is, therefore, likely to be a marker of eosinophilic inflammation in the airway
as eosinophils release fibrogenic mediators

 The airway wall itself may be thickened and edematous, particularly in fatal asthma.

o Another common finding in fatal asthma is occlusion of the airway lumen by a mucous plug,
which is comprised of mucous glycoproteins secreted from goblet cells and plasma proteins from
leaky bronchial vessels
Reading Assignment: Asthma and GINA guidelines

o There is also vasodilation and increased numbers of blood vessels (angiogenesis)

 Direct observation by bronchoscopy indicates that the airways may be narrowed, erythematous,
and edematous.

Diagnosis
 Usually apparent from the symptoms of variable and intermittent airway obstruction, but must be
confirmed by objective measurements of lung function

 Spirometry
Reading Assignment: Asthma and GINA guidelines

o Confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio and 200 - mL increase in
FEV1 15 min after an inhaled short - acting ꞵ2 - agonist or in some patients by a 2 – 4 week
trial of oral corticosteroid
o Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio, and PEF
o Reversibility is demonstrated by a >12% and 200-mL increase in FEV1 15 min after an
inhaled short-acting β2- agonist or in some patients by a 2- to 4-week trial of oral
corticosteroids (OCS) (prednisone or prednisolone 30–40 mg daily).

 Chest X-ray

o Usually normal but in more severe patients may show hyperinflated lungs. In exacerbations,
there may be evidence of a pneumothorax. Lung shadowing usually indicates pneumonia or
eosinophilic infiltrates in patients with broncho-pulmonary aspergillosis (BPA).
 High Resolution CT Scan
o Usually normal but may show areas
of bronchiectasis in patients with severe asthma, and there may be thickening of the
bronchial walls, but these changes are not diagnostic of asthma.

Management
 ICS
o Most effective anti-inflammatory agents and controllers
o Reduce inflammatory cell numbers and their activation, eosinophils in airways and sputum,
activated T lymphocytes, and surface mast cells reducing airway hyperresponsiveness in
chronic ICS therapy
o Recruitment of HDAC2Treverses histone acetylation
o Usually given twice daily; once daily in mildly symptomatic patients
 LABA (Salmeterol and Formoterol)
o Duration of action: 12hrs, twice daily by inhalation
o Should not be given in the absence of ICS therapy
 LAMA (Tiotropium bromide or Glycopyronium bromide)
o Additional bronchodilator with asthma uncontrolled by maximal doses of ICS-LABA
combinations
Reading Assignment: Asthma and GINA guidelines
Reading Assignment: Asthma and GINA guidelines
Reading Assignment: Asthma and GINA guidelines