ASTHMA

Dr.Sathaporn Kunnathum 19 January 2010

when you were born you were crying and everyone around was smiling, live your life so that when you die, you are smiling and everyone is around crying. Anonymous

Current Understanding of Asthma
   

A chronic inflammatory disorder of the airway Infiltration of mast cells, eosinophils and lymphocytes Airway hyperresponsiveness Recurrent episodes of wheezing, coughing,chest tightness and shortness of breath reversible airflow limitation

The Underlying Mechanism
Risk Factors (for development of asthma)

INFLAMMATION
Airway Hyperresponsiveness

Airflow Limitation

Symptoms- (shortness Risk Factors of breath, cough, chest (for exacerbations) tightness, wheeze)

Asthma: Pathological changes

Risk Factors that Lead to Asthma Development
Predisposing Factors

Atopy

Contributing Factors
Respiratory infections Small size at birth  Drugs and Diet  Strong emotional expression  Air pollution
 

Causal Factors

Indoor Allergens
– – – –

Outdoor Allergens
– Pollens – Fungi

Domestic mites Animal Allergens Cockroach Allergens Fungi

– Outdoor pollutants – Indoor pollutants

Smoking
– Passive Smoking – Active Smoking

Occupational Sensitizers

DIAGNOSIS OF ASTHMA
  

History and patterns of symptoms Physical examination Measurements of lung function

PATIENT HISTORY
   

Has the patient had an attack or recurrent episodes of wheezing? Does the patient have a troublesome cough, worse particularly at night, or on awakening? Does the patient cough after physical activity (eg. Playing)? Does the patient have breathing problems during a particular season (or change of season)?

Do the patient’s colds ‘go to the chest’ or take more than 10 days to resolve?  Does the patient use any medication (e.g. bronchodilator) when symptoms occur? Is there a response? If the patient answers “YES” to any of the above questions, suspect asthma.

Physical Examination
Wheeze

Usually heard without a stethoscope
Dyspnoea

Rhonchi heard with a stethoscope Use of accessory muscles
Remember

Absence of symptoms at the time of examination does not exclude the diagnosis of asthma

Diagnostic testing
Diagnosis of asthma can be confirmed by demonstrating the presence of reversible airway obstruction using Spirometry. Peak flow meter.

FEV1
F rc Ep to V lu ein1s c n o e x ira ry o m eo d

FVC
F rc V l Cp c o e ita a a ity

(spirometry)

Peak Flow meter

Bronchodilator Test
  

Peak Flow before and after bronchodilator 15 min FEV1 > 12 % is asthma PEFR > 15 % is asthma

•Salbutamol inhaler 2 puffs •wait 15 minutes

PEFR increase
390-300 300

PEFR =300 L/min

PEFR =390 L/min

= 30%

GINA 2006
Assessing asthma control

•Day symptoms •Night symptoms •Reliever •PEFR •Exacerbation •Limitation of activity •Controlled •Partly controlled •Uncontrolled

2006

Treating to achieve asthma control
1. 2. 3. 4. 5.

B2-agonist prn ICS ICS (low dose) + LABA ICS (high dose) + LABA ICS (high dose) + LABA + prednisolone

Monitoring to maintain control

Levels of Asthma Control
Characteristic Controlled (All of the following) Partly Controlled Uncontrolled (Any measure present in any week) Three or more features of partly controlled asthma present

Daytime symptoms Limitations of activities Nocturnal symptoms/awakening Need for reliever/ rescue treatment Lung function (PEF or FEV1)‡ Exacerbations

None (twice or less/week)More than twice/week None None Any Any

None (twice or less/week)More than twice/week Normal None < 80% predicted or personal best (if known) One or more/year* One in any week†

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate. † By definition, an exacerbation in any week makes that an uncontrolled asthma week. ‡ Lung function is not a reliable test for children 5 years and younger.

Pharmacological therapy
 Relievers

 Controllers
 Inhaled

Inhaled fast-acting β 2-agonists

corticosteroids

 Inhaled  Oral

long-acting β 2-agonists

anti-leukotrienes  Oral theophyllines

Simplified asthma treatment
Asthma Patient
No day symptoms No night symptoms No rescue medication No ER visit PEFR >80%

Total control

Assess Control

Treatment

ICS 500ug/d

ICS 500ug/d + Other controller

Goals to Be Achieved in Asthma Control
     

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Minimal use of reliever medication No emergency visits to doctors or hospitals Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal as possible Minimal (or no) adverse effects from medicine

Inhalation devices you can use

Dry Powder Inhaler

Metered Dose inhaler

Spacer

Age-wise selection of inhaler devices
 

< 3 years – MDI + Spacer + Mask or nebulisers 3 – 5 years – MDI + Spacer + Mask or Rotahaler 5 – 8 years – Rotahaler or MDI + Spacer > 8 years – Rotahaler or MDI + Spacer

 

Key Messages
      

Asthma is a common disorder It can happen to anybody It is not caused by supernatural forces Asthma is not contagious It produces recurrent attacks of cough with or without wheeze Between attacks people with asthma lead normal lives as anyone else In most cases there is some history of allergy in the family.

Key Messages

Asthma can be effectively controlled, although it cannot be cured. Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy. A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication.

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