ASTMUL BRONSIC

CAZ 1
varsta: 66
• Dan B. Pascaru

• HTA de la 45 ani
– Amlodipina
– Perindopril
 Caz 1
• A oprit medicatia din sept 2019
 CAZ 1

• Simptome (de 2 zile)

– Tuse
– dispnee

• Semne:
– Wheezing
– crepitante
 CAZ 1

• Simptome (de 2 zile)

– Tuse
– dispnee

• Semne:
–Wheezing
– crepitante
 DIAGNOSTIC

• CRIZA ASTMATICA ?
 Teste de Laborator ?
PRIMA LINIE A DOUA LINIE
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup arteria
• BNP
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup arteria
• BNP=12.000
Beta2 mimetice ! prof

• Tahicardie
• Aritmii
• Ischemie miocardica
 CAZ 2
varsta: 16
Melinda Pasca
• Antecedente de astm

• 2 crize la varsta de 14

• 2 crize/an

• Fara medicatie
 Caz 2
Simptome (2 hours)
• tahipnee
• dispnee instalata brusc
• wheezing

“simt ca ma sufoc”

Signs:
Wheezing
FC 110, FR 40
 DIAGNOSTIC

• CRIZA ACUTA DE ASTM ?

 Teste de laborator
PRIMA LINIE A DOUA LINIE
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup
• BNP
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup
• BNP
 Hemograma

• Hb=12,7 • VSH=14 mm (N=0-9mm)

• L=7000 • CRP=N
• Tr=230.000
• Fbg=N
• Eosinofile =15%
N=(1-4%)
 TESTE PARACLINICE
PRIMA LINIE A DOUA LINIE

• EKG • Spirometrie
• Rx
• Ecco cord
 TESTE PARACLINICE
PRIMA LINIE A DOUA LINIE

• EKG • Spirometrie
• Rx
• Ecco cord
 TESTE PARACLINICE
PRIMA LINIE A DOUA LINIE

• EKG • Spirometrie
• Rx
• Ecco cord
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup
• BNP
 Arterial Blood Gases ?

pH= 7.5, PaCO2= 27, HCO3- =22 PaO2= 75

pH PaCO2 HCO3- PaO2

   (Slightly) 
 DIAGNOSIS: ASTHMA
• Mild ?
• Moderate ?
• Severe ?
 Laboratory Tests
PRIMA LINIE A DOUA LINIE

• Hemograma
• Biochimie
• Coagulare

• Astrup

• BNP=120
ASTMUL BRONSIC
 DEFINITIE
Boala acuta sau cronica ?
 DEFINITIE
• Afectare cronica a cailor aeriene
• Caracterizata prin:
--simptome recurente
– Sindrom bronsic obstructiv
– Hiperreactivitate bronsica
– Inflamatie a bronsiolelor
 EPIDEMIOLOGIE
Intr-un amfiteatru de 30 de studenti,

te poti astepta sa ai 2-3 studenti cu ASTM

BRONSIC
 Etiologie
• Astm extrinsec
– Alergic sau atopic

• Astm intrinsec
– Nonalergic/nonatopic
 SUBSTRATUL ANATOMIC

• Constritie a musculaturii netede din bronsiole

(bronchospasm)
• Productie excesiva de secretii bronsice groase, albe, adezive
• Hiperinflatie alveolara (air-trapping)
• Obstructii cu mucus iar in cazuirle severe, Atelectazie.
Figure 13-2. The immunologic mechanisms in asthma.
 Astmul intrinsic
(Nonalergic sau Nonatopic)
• Infectii
• Exercitiu fizic sau aer rece
• Poluanti industriali sau expunere ocupationala.
• Medicamente, aditivi alimentary, conservanti
• Reflux gastro-esofagian
• Somn ( astm nocturn)
• Stress emotional
• Astm premenstrual
EXAMEN CLINIC
 EXAMiNARE
SEMNE VITALE
• Creste frecventa respiratorie (VN 12/min)
• Creste frecventa cardiaca, TA, debitul cardiac
Hipersonoritate la percutie pulmonara
Murmur vezicular diminuat + sibilante+ronflante
 Clinical Data
Examinarea toracelui
• Expir prelungit 1:3, 1:4
• Freamat pulmonar diminuat
• Hipersonoritate la percutie
• Murmur respirator diminuat
• Sibilante si Ronflante
• Zgomote cardiace diminuate
 Examen clinic
• Manifestari generale
• Muschi accesori pentru inspir
• Muschi accesori pentru expir
• Retractii intercostalesubsternale
• Substernal intercostal retractions
• Diametru AP crescut
• Cianoza
• Tuse+/- sputa
• Pulsus paradoxus
 Examen clinic
Pulsus paradoxus
• Inspir – scade presiunea pulsului
• Expir-creste presiunea pulsului
 Puls paradoxal
• Scade TA in inspir
 MANIFESTARI NON-PULMoNARE

• Semne de alergie sau atopie

• Semne cutanate de alergie

TESTE DE LABORATOR
 TESTE DE LABORATOR
PRIMA LINIE A DOUA LINIE

• Complete blood count • Sputum examination

• Biochemistry
• Coagulation

• Arterial Blood Gases

• BNP
 Laboratory Tests
FIRST LINE SECOND LINE

• Complete blood • Sputum examination

count
• Biochemistry
• Coagulation

• Arterial Blood Gases

• BNP
 HEMOGRAMA

- Blood eosinophilia greater than 4% or 300-400/µL is

consistent with the diagnosis of asthma, but

- a normal value is not exclusionary.

- IgE >100 IU patients with allergic reactions

- test for allergic sensitivity :

- allergy skin tests (Prick test)

- blood radioallergosorbent tests (RAST).

 TESTE PARACLINICE
FIRST LINE SECOND LINE

• EKG • Pulmonary Function Study

• Chest radiograph
• Echocardiography
 TESTE PARACLINICE
FIRST LINE SECOND LINE

• EKG • Pulmonary Function Study

• Chest radiograph
• Echocardiography
 Rx TORACIC
Chest radiograph

• Normal
• Hyperinflation
– Increased anteroposterior diameter
– Translucent (dark) lung fields
– Depressed or flattened diaphragm
Figure 13-4. Chest X-ray of a 2-year-old patient during an acute asthma attack.
 TESTE DE LABORATOR
FIRST LINE SECOND LINE

• Complete blood count • Sputum examination

• EKG
• Chest radiograph

• Arterial Blood Gases

• BNP
 ASTRUP ARTERIAL

• pH=7,35-7,45
• paCO2=35-45mmHg
• SaO2=93-98%
• paO2=80-100mmHg
• HCO3=24-26mEq/l
 ASTRUP ARTERIAL

Mild to Moderate Asthma Episode

 Acute alveolar hyperventilation with hypoxemia

pH PaCO2 HCO3- PaO2

   (Slightly) 
 ASTRUP ARTERIAL

Severe Asthmatic Episode (Status Asthmaticus)

 Acute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

   (Significantly) 
 Laboratory Tests
FIRST LINE SECOND LINE

• Complete blood count • Pulmonary Function Study

• EKG • Sputum examination
• Chest radiograph

• Arterial Blood Gases

• BNP

ratio
RESTRICTIVE

OBSTRUCTIVE
NORMAL
OBSTRUCTIE
DUPA BRONHODILATATOR
 TESTE DE LABORATOR
FIRST LINE SECOND LINE

• Complete blood count

• Biochemistry
• Sputum examination
• Coagulation

• Arterial Blood Gases

• BNP
 Examinarea Sputei

• Eosinophils
• Charcot-Leyden crystals (see next slide)
• Casts of mucus from small airways
–called Kirschman spirals
• IgE level (elevated in extrinsic asthma)
 Charcot-Leyden Crystals

Needle shaped crystals -

Represents breakdown products of
eosinophils
 DIFFERENTIAL DIAGNOSIS ?
• LEFT HEART FAILURE

• COPD
HEART FAILURE
COPD
 PARACLINICAL EXAMINATIONS
• Pulmonary Function Testing
-the degree of reversibility in FEV1 which indicates a
diagnosis of asthma is generally accepted as

≥ 12% and

≥ 200 ml

from the pre-bronchodilator value the administration of a

short-acting bronchodilator.
  

ASTHMA Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

  

COPD Figure 9-11. Excessive bronchial secretions clinical scenario.

GINA

FEV 1 > 80%

GINA

FEV 1 > 80%

FEV 1 > 80%
GINA

FEV 1 > 80%

FEV 1 > 80%
FEV 1 =60- 80%
GINA

FEV 1 > 80%

FEV 1 > 80%
FEV 1 =60- 80%
FEV 1<60%
TRATAMENT
1. Wich of the folowing are clinical findings in
asthma ?

a) Wheezing
b) Retrosternal thoracic Pain
c) Diminished breath sounds at auscultation
d) Decreased heart rate (bradycardia)
e) Hepatomegaly, jugular distension and edema
 2. In asthma, laboratory tests show:

a) Elevated BNP > 12.000

b) Increased anteroposterior diameter in X-ray
c) Elevated pH in mild to moderate asthma
d) restrictive respiratory disfunction in
spirometry
e) Thrombus in right pulmonary artery
3. What is the treatment for acute asthmatic
chrisis ?

a) Symbicort 3-4 times a day

b) Spiriva 1/day
c) Salbutamol
d) Oxygen
e) Intravenous Amynophiline
TREATMENT
 TREATMENT
• 1
• 2
• 3
• 4
• 5
• 6
 IgE
antagonist

R
cromones

1 2 3 4 5
CLASSIFICATION 3
 CLASIFICATION 3
bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
BRONCHOSPASM

vegetativ

2 anticholinergics
simpaticomimetics

direct methilxantines
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 1 Beta2 agonists
• Short-acting • Long-acting

• FENOTEROL • FORMOTEROL
• SALBUTAMOL • SALMETEROL
• TERBUTALINE

4 hours 12 hours
 1 Beta2 agonists
• Short-acting • Long-acting

• FENOTEROL =BEROTEC • FORMOTEROL=OXIS

• SALBUTAMOL =VENTOLIN TURBUHALER
• TERBUTALINE =BRYCANIL • SALMETEROL=SEREVENT

SELECTIVES 12 hours
4 hours
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 2 Anticholinergics
• Short-acting • Long-acting

• IPRATROPIUM
BROMIDE • TIOTROPIUM

• OXITROPIUM
BROMIDE
 2 Anticholinergics
• Short-acting • Long-acting

• IPRATROPIUM
BROMIDE=IPRAVENT • TIOTROPIUM =SPIRIVA

• OXITROPIUM
BROMIDE=ATROVENT

6 hours 24 hours
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 3 Methylxantines
• Short-acting • Long-acting

• Aminophyline • Theophyline (SR)

 3 Methylxantines
• Short-acting • Long-acting

• Aminophyline • Theophyline (SR)

=MIOFILIN
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 4 Glucocorticosteroids
• Systemic • Inhaled

• Prednisone • Beclomethasone
• Methyl-prednisolone • Budesonide
• Fluticasone

HHC in acute form Long action

 4 Glucocorticosteroids
• Systemic • Inhaled

• Prednisone • Beclomethasone=BECOTIDE
• Methyl-prednisolone • Budesonide=PULMICORT
• Fluticasone=FLIXOTIDE

HHC in acute form Long action

 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 5 Phosphodiesterase-4inhibitors

• Cromolyn
• Nedocromil
 5 Phosphodiesterase-4inhibitors

• Cromolyn =INTAL
• Nedocromil=TILADE
 bronchospasm

1 beta2 simpaticomimetics
2 anticholinergics

3 methylxanthines

Inflamation and edema

4 glucocorticosteroids

Mastocite degranulation

Phosphodiesterase-4 inhibitors 5

Leukotriene inhibitors 6
 6 Leukotriene -inhibitors

• Montelukast
• Zafirlukast
• Zileuton
 6 Leukotriene -inhibitors

• Montelukast =SINGULAIR 1/day

• Zafirlukast=ACCOLATE 2/day
• Zileuton=ZYFLO 4/day
 COMBINATIONS – in one inhaler
• Short-acting • Long-acting
β 2 agonist plus β 2 agonist
anticholinergic plusglucocorticosteroids

FENOTEROL+IPRATROPIUM FORMOTEROL+BUDESONIDE

SALBUTAMOL+IPRATROPIUM SALMETEROL+FLUTICASONE
 COMBINATIONS – in one inhaler
• Short-acting • Long-acting
β 2 agonist plus β 2 agonist
anticholinergic plusglucocorticosteroids

FENOTEROL+IPRATROPIUM= FORMOTEROL+BUDESONIDE=
BERODUAL SYMBICORT

SALBUTAMOL+IPRATROPIUM= SALMETEROL+FLUTICASONE=
COMBIVENT SERETIDE

25/50 25/125 25/250

 ASTHMATIC CRISYS TREATMENT
• ?
• ?
• ?
• ?
• ?
 ASTHMATIC CRISIS TREATMENT
• 1)Beta2 mimetics (VENTOLIN)
• 2)ATROVENT (IPRATROPIUM BROMIDE)
• 3)AMYNOPHILINE (Miofilin 1-1-1 inj//day)
• 4) HHC 100mg (1-0-1 inj/day)
• 5)______
• 6)______
 ASTHMATIC CRISIS TREATMENT
• Oxygen
• Antibiotics : Ampiciline, Cefalosporines, Quinolones
• Mucolitics: water, Acetilcisteine 3/day, Bromhexine.
• Bicarbonate

• ADRENALINE 0,3-0,5 ml
• Prednisone 30-40 mg/day < 5 mg/5 days
• Mechanical ventilation
 CHRONICAL TREATMENT
• 1)Long acting beta 2 mimetics: Serevent
• 2)___________COPD
• 3)Teotard
• 4) inhaled glucosteroids: Becotide, Pulmocort, Flixotide
• 5) Cromolyn, Nedocromil
• 6)Leukotriene inhibitors: Singulair, zafirlukast, Zileuton
CLASSIFICATION 2
Beta2 mimetics !

• Tachycardia
• Arrhytmias
• Myocardial ischemia
 OMALIZUMAB
• Monoclonal antibody
against IgE
• Expensive and requires
monthly injections
• Most effective if allergies
trigger asthma
• Children with
documented allegries
• Not for children without
allergies
 IgE
antagonist

R
cromones

1 2 3 4 5