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BRONCHIAL ASTHMA IN

ADULT
Zulkarnain Arsyad
Pulmonary Sub. Division of Internal
Medicine Medical Faculty Andalas
University M.Djamil Hospital Padang

What is Asthma?
Chronic inflammatory disorder of airways
Inflammation causes airway hyper responsiveness often associated with
symptoms (wheeze, cough, SOB).
Obstruction is reversible

Introduction
In the community prevalence of bronchial asthma
approximately are 4 6 %
Prevalence of asthma appears to be increasing in
the children than adult
In the population, male asthmatic patients
approximately are same with the female asthmatic
patients
The are various factors, such as the environment,
socio economic status, climate and ethnic group
have the role in the prevalent of asthma

Pathogenesis
:
Airway
Hyperresponsiveness
Genetic*

INDUCERS
Allergens,Chemical sensitisers,
Air pollutants, Virus infections

INFLAMMATION
Airflow Limitation

TRIGGERS
Allergens, Exercise,
Cold Air, SO2 Particulates

SYMPTOMS
Cough Wheeze
Dyspnoea

Pathogenesis - Atopic Asthma:

Mast cells in Asthma Pathogenesis:

Eosinophils in Asthma
Pathogenesis:

Asthma - Bronchial morphology


inflammation
Eosinophils
Gland
hyperplasia
Mucous plug in
lumen
Hypertrophy of
muscle layer

Pathophysiology of asthma
Variety of stimuly
chronic a.w inflamation/ HBR
Acute reversible a.w obst
Inflamatory component

early respont
late respont

Patophysiology of asthma
Airway inflamation

Reversible a.w obstrc, Hallmarks :


- Smooth msc contrct
- Oedem
- Mucous hyper secretion
Mast cell
histamin release etc,
broncho constriction

What is the Pathophysiology of


Asthma?
Pathological changes found in asthma are the 3 Ss:
1. Spasm of smooth muscle hypertrophy which
contracts during an attack
2. Swelling or oedema of bronchial mucosa
3. Secretions from hypertrophy of mucus glands
leading to thick & tenacious mucus
All the above cause bronchial narrowing

Pathophysiology of Asthma
If left untreated chronic airway inflammation may
lead to permanent airway changes
Airway thickening causes irreversible airflow limitation
and shortened life expectancy

Common Asthma Triggers

URI
Allergens
Aerobic Exercise
Irritants
Air Pollution
Strong emotions
Medications
Beta blockers

Clinical Presentation

Wheezing
Dyspnea
Chest tightness
Use of accessory respiratory muscle
Central or peripheral cyanosis
Tachycardia
Prolonged expiration
Altered mental status

Classification of Severity
CLASSIFY SEVERITY

Clinical Features Before Treatment


Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent

Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day

Nocturnal
Symptoms
Frequent

> 1 time week

> 2 times a month

FEV1 or PEF
60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
80% predicted

Variability 20 - 30%

< 1 time a week


STEP 1
Intermittent

Asymptomatic
and normal PEF
between attacks

2 times a month

80% predicted
Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

What is an Asthma Exacerbation?


Episodes of progressive increase in
shortness of breath, cough, wheezing, or
chest tightness, or some combination of
these symptoms.2

2. Global Strategy for Asthma Management and Prevention


www.ginaasthma.org

Cont What is an Asthma Exacerbation?


Represent an exaggerated lower airway response to an
environmental stimulus.
Respiratory viral infection - main trigger of severe
exacerbations of asthma.
Airway inflammation is a key pathogenic feature

Which aspects of asthmatics history are


important to current exacerbation?
Other Qs3
Prior hospitilizations
ICU admissions
Recent ED visits
Current meds
Co-morbid conditions

3. Emergency Medicine Secrets 4th Edition

GOALS OF TREATMENT

Maintain adequate oxygenation


Relieve airflow obstruction
Reduce airway inflammation
Prevent future relapses
- Elimination of causative agents from the
environment of an asthmatic individual

THERAPY
QUICK-RELIEF MEDICATIONS (RELIEVER)
LONG-TERM CONTROL MEDICATIONS
(CONTROLLER)

Stepwise Approach to Asthma Therapy: Adults

Step 1: Intermittent Asthma


Daily Controller
Medications
None required

Reliever
Medications
Rapid-acting inhaled 2-agonist
for symptoms (but < 3-4times/day)
Rapid-acting inhaled 2-agonist,
cromone, or leukotriene modifier
before exercise or exposure to
allergen

Continuously review medication technique, compliance and environmental control


Review treatment every three months.
Step up if control is not achieved; step down if control is sustained for at least 3 months
Preferred treatments are in bold print

Stepwise Approach to Asthma Therapy: Adults

Step 2: Mild Persistent Asthma


Daily Controller
Medications

Reliever
Medications

Inhaled glucocorticosteroid
(< 500 g BDP or equivalent)

Rapid-acting inhaled 2-agonist


for symptoms (but < 3-4 times/day)

Other options (order by cost):


sustained-release theophylline, or
Cromone, or
leukotriene modifier

Other options:
inhaled anticholinergic, or
short-acting oral 2-agonist, or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months
Step up if control is not achieved; Step down if control is sustained for at least 3 months
Preferred treatments are in bold print

Stepwise Approach to Asthma Therapy: Adults

Step 3: Moderate Persistent Asthma


Daily Controller
Medications
Inhaled glucocorticosteroid, (200 1000 g BDP or
equivalent) plus long-acting inhaled 2agonist
Other options (order by cost):
Inhaled glucocorticosteroid (500 1000 g BDP equivalent)
plus sustained-release theophylline, or
Inhaled glucocorticosteroid (500 1000 g BDP equivalent)
plus long-acting inhaled 2- agonist, or

inhaled glucocorticosteroid at higher doses


(> 1000 g BDP equivalent), or

Inhaled glucocorticosteroid
plus leukotriene modifier

(500 1000 g BDP equivalent)

Reliever
Medications
Rapid-acting inhaled
2-agonist for symptoms
(but < 3 - 4 times/day)
Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.

Stepwise Approach to Asthma Therapy: Adults

Step 4: Severe Persistent Asthma


Daily Controller
Medications

Reliever
Medications

Inhaled glucocorticosteroid, (> 1000 g


BDP or equivalent) plus long-acting
inhaled 2agonist

Rapid-acting inhaled
2-agonist for symptoms
(but < 3-4 times/day)

plus one or more of the following, if


needed (order by cost):
sustained-release theophylline, or
leukotriene modifier or
oral glucocorticosteroid

Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
short-acting theophylline

Continuously review medication technique, compliance and environmental control.


Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print .

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma


Therapy - Adults
Outcome: Best
Possible Results

Outcome: Asthma Control

Controller:

Controller:
Controller:
None

Controller:
Daily inhaled
corticosteroid

Daily inhaled
corticosteroid
Daily longacting inhaled
2-agonist

Daily inhaled
corticosteroid
Daily long
acting inhaled
2-agonist
plus (if needed)

-Theophylline-SR
-Leukotriene
-Long-acting inhaled
2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor

Reliever: Rapid-acting inhaled 2-agonist prn


STEP 1:
Intermittent

STEP 2:
Mild Persistent

STEP 3:
Moderate
Persistent

STEP 4:
Severe
Persistent

STEP Down

Alternative controller and reliever medications may be considered

Principles of treatment
Use quick-relief rescue medication for all
pt
Persistent asthma requires :
Long-term-control medication
anti-inflammatory meds preferred
Step up treatment if control not maintained
Step down if in control

Management of
Asthma Exacerbations:
Key Points

Early treatment is best. Important elements include:


A written action plan
Guides patient self-management of exacerbations
at home
Especially important for patients with moderateto-severe persistent asthma and any patient with
a
history of severe exacerbations
Recognition of early signs of worsening asthma

Management of
Asthma Exacerbations:
Key Points (continued)

Appropriate intensification of therapy

Prompt communication between patient


and clinician about:
Serious

deterioration in symptoms or peak flow,

or
Decreased

responsiveness to inhaled
beta2-agonists, or

Decreased

duration of beta2-agonist effect

Management of
Asthma Exacerbations

Inhaled beta2-agonist to provide prompt


relief of airflow obstruction

Systemic corticosteroids to suppress


and reverse airway inflammation

For moderate-to-severe exacerbations, or

For patients who fail to respond promptly


and completely to an inhaled beta2-agonist

Management of
Asthma Exacerbations (continued)

Oxygen to relieve hypoxemia for


moderate-to-severe exacerbations

Monitoring response to therapy with


serial measurements of lung function

Risk Factors for


Death From Asthma
Past history of sudden severe
exacerbations
Prior intubation or admission to ICU
for asthma
Two or more hospitalizations for asthma
in the past year
Three or more ED visits for asthma
in the past year

Risk Factors for


Death From Asthma (continued)

Hospitalization or an ED visit for asthma


in the past month

Use of >2 canisters per month of


inhaled short-acting beta2-agonist

Current use of systemic corticosteroids


or recent withdrawal from systemic
corticosteroids

Risk Factors for


Death From Asthma (continued)
Difficulty perceiving airflow obstruction
or its severity
Comorbidity, as from cardiovascular
diseases or chronic obstructive
pulmonary disease
Serious psychiatric disease or
psychosocial problems