ASTHMA

Group 1
TABLE OF CONTENT
INTRODUCTION 3

DIAGNOSIS 12

MANAGEMENT 22

PATIENT COUNSELLING 34
INTRODUCTION
• Asthma is a medical condition characterized by the chronic inflammation of
the airways

• The airways of affected patients become

narrower with increased mucus production.

• The bronchioles become hypersensitive

which leads to bronchospasms.

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INTRODUCTION
 Pathophysiology
• Airway inflammation: Characterized by swelling and thick mucus
production.

• Airway hyper-responsiveness: Characterized by abnormal sensitivity of

the airways to wide range of external stimuli.

• Bronchoconstriction: Characterized by constriction of the bronchial

muscles.

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INTRODUCTION
 Characters present in the airway of an asthmatic patient
• These are grouped into inflammatory cells and inflammatory mediators.

• The inflammatory cells are lymphocytes, mast cells, eosinophils,

neutrophils, macrophages, dendritic cells and epithelial cells.

• The inflammatory mediators present are chemokines, cytokines,

cysteinyl-leukotrienes, nitric oxide and immunoglobulin E.

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INTRODUCTION
 Triggers and Risk Factors
• Sex
• Family History
• Viral respiratory tract infection
• Allergens

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DIAGNOSIS
• Detailed medical history

• Physical exam: focuses on the upper respiratory tract, chest and skin.

• Pulmonary function test: Consists of spirometry, exhaled nitric oxide test

and the bronchoprovocation test(methacholine test).

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DIAGNOSIS
 Spirometry (FEV1/FVC)
• Helps to determine airflow obstruction, it’s severity and whether it is
reversible over a short term.
• Spirometry sometimes reveals obstruction much more severe than would
have been estimated from the history and physical examination.
• FEV1 = forced expiratory volume in 1s(i.e. volume of air breathed out in
first second with maximal effort after maximal inspiration).
• FVC= forced vital capacity is the volume of air that can forcibly be
blown out after full inspiration, measured in liters.

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DIAGNOSIS
 Exhaled Nitric Oxide Test
• Nitric oxide is a gas produced in the lungs and it acts as a major indicator
of inflammation.

• The test is performed by having you breathe into a small

handheld machine for about 10 seconds at a steady pace.
It then calculates the amount of nitric oxide you breathe out.

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DIAGNOSIS
 Bronchoprovocation test
• In this test, spirometry is performed using increasing doses of
methacholine.

• If patient has asthma-lung function will drop by at least 20% during

the test.

• A bronchodilator medication would be given at the end of the test.

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DIAGNOSIS
 Bronchoprovocation test
• This test is contraindicated in the following group of people:
• Pregnant woman.
• Stroke or heart attack in the past three months.
• Aortic or cerebral aneurysm.
• Uncontrolled high blood pressure.

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DIAGNOSIS
 Peak expiratory flow rate(PEFR)
• Peak flow at the beginning of an expiration delivered with maximal force
from a fully inflated chest, units litres min-1. Varies with age and sex so
require a nomogram to predict value.

• For diagnostic purposes, spirometry is generally recommended over

measurements by a PEFR because of the wide variability between the
peak expiratory flow reference values.

• Peak flow meters are designed as monitoring, not as diagnostic.

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DIAGNOSIS
 Classifications
• Mild intermittent asthma
• Mild persistent asthma
• Moderate persistent asthma
• Severe persistent asthma

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MANAGEMENT
 Goals of therapy
• To prevent and control asthma symptoms
• Reduce the frequency and severity of asthma exacerbations
• And reverse airflow obstruction.
• Improve quality of life

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MANAGEMENT
 Medications used are categorized into two classes:
• Long-term control medications(Preventive, controller or maintenance
medications) which are taken daily on a long-term to achieve and
maintain control of persistent asthma

• Quick-relief medications(reliever or rescue medications) which are taken

to provide prompt reversal of asthma.

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MANAGEMENT
 Daily Long-Term Control:
• Corticosteroids (inhaled and systemic)
• Long-acting beta2-agonists (salmeterol, formoterol) when in combination
with ICS
• Leukotriene modifiers (montelukast)
• Leukotriene inhibitors (zileuton)
• Mast cell stabilizers (cromolyn or nedocromil)
• Methylxanthines (theophylline)

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MANAGEMENT
 Long Acting Beta 2 Agonists (LABA)
• Salmeterol and formoterol are bronchodilators that have a duration of
bronchodilation of at least 12 hours after a single dose.

• LABAs are not to be used as monotherapy for long-term control of

asthma.

• LABAs are used in combination with ICSs for long-term control and
prevention of symptoms in moderate or severe persistent asthma care or
higher in children ≥5 years of age and adults

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MANAGEMENT
 Long Acting Beta 2 Agonists (LABA)
• LABA may be used before exercise to prevent EIB but duration of action
does not exceed 5 hours with chronic regular use.

• Frequent and chronic use of LABA for EIB is discouraged, because this use
may disguise poorly controlled persistent asthma

• The use of LABA for the treatment of acute symptoms or exacerbations is

not recommended

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MANAGEMENT
 Corticosteroids(beclomethasone, budesonide)
• Block late-phase reaction to allergen, reduce airway hyperresponsiveness,
and inhibit inflammatory cell migration and activation.
• Inhibit release of mediators from macrophages and eosinophils
• They are the most potent and effective anti-inflammatory medication
currently available
• Inhaled corticosteroids are used in the long-term control of asthma.
• Long-term oral systemic corticosteroid is used for severe persistent
asthma.

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MANAGEMENT
 Inhaled Corticosteroids
• Some benefits associated with the daily use of this medication is reduced
airway inflammation, improved lung function, reduced use of quick-relief
medicine and fewer symptoms and exacerbations

• ICS do not provide short-term relief in usual doses.

• Possible side effects associated are oral candidiasis (thrush), dysphonia,

dermal thinning and skin bruising.

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MANAGEMENT
 Mast Cell Stabilizer(e.g., cromolyn, nedocromil)
• Stabilize mast cells and interfere with chloride channel function.
• Inhibit release of histamine
• Inhibit late-phase response
• Long-term administration can prevent and reduce bronchial hyper-
reactivity. Used as alternative, but not preferred, medication for the
treatment of mild persistent asthma
• Effective in exercise-induced asthma when used 10 to 20 minutes before
exercise

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MANAGEMENT
 Leukotriene Modifiers(montelukast, zafirlukast)
• They have broncho-dilator and anti-inflammatory effects
• The 5-lipoxygenase pathway inhibitor zileuton(leukotriene) is available for
patients ≥12 years of age; liver function monitoring is essential.
• Monotherapy in mild persistent asthma
• Add-on therapy in moderate to severe persistent asthma

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MANAGEMENT
 Methylxanthines:
• Sustained-release theophylline is a mild to moderate bronchodilator used
as alternative, not preferred, adjunctive therapy with ICS
• Theophylline may have mild anti-inflammatory effects.
• Monitoring of serum theophylline concentration is essential.

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MANAGEMENT
 Quick Relief Medications
• Anticholinergics: Ipratropium bromide provides additive benefit to SABA
in moderate-to-severe asthma exacerbations. May be used as an
alternative bronchodilator for patients who do not tolerate SABA
• Short Acting B2 Agonist (SABAs): salbutamol and terbutaline are
bronchodilators that relax smooth muscle. Therapy of choice for relief of
acute symptoms and prevention of EIB
• Systemic corticosteroids: Although not short acting, oral systemic
corticosteroids are used for moderate and severe exacerbations as adjunct
to SABAs to speed recovery and prevent recurrence of exacerbations

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MANAGEMENT
 New Therapy
• Anti-IgE Therapy – Omalizumab (Xolair)
• Humanized IgG (5% murine)
• Binds IgE regardless of specificity
• Does not activate complement
• Rarely has caused anaphylaxis

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PATIENT COUNSELLING
• Always rinsing mouth before using ICS
• Using a spacer is advisable to avoid oral thrush
• Using lowest dose of SABA possible that results in control
• Use SABA in combination with LABA or a leukotriene modifier if the
condition is moderate/severe.
• SABA should be taken 5-30minutes before exercise to reduce risk of attack
• Advice patient to avoid triggers

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THANK YOU