Bronchial Asthma

Alinur A, MD
May 2012

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 Definition
• B.Asthma is a diffuse obstructive lung disease
with hyper reactivity of the airways &
reversibility of the air flow obstruction
spontaneously or with treatment

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 Epidemiology
• worldwide 100 to 200 million cases of asthma are seen
yearly
• accounts for 40,000 to 50,000 deaths
• it is rare in rural setting
• Increasing industrialization & urbanization is associated
with high incidence of asthma
• children are more affected than adults
• most children will have their 1st symptoms before 5 years
of age
• children with severe chronic asthma & steroid
dependence have high (95%) chance of becoming adult
asthmaticus 3
 Risk factors
• Allergy ( inherited) like eczema, urticaria or
hay fever
• Polygenic inheritance: if one parent has
asthma, there is 25% risk of asthma in their
child. If both parents are affected, there is a
50% chance
• LBW
• Poverty, frequent respiratory infections

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 Etiology
• there is no well-defined single etiologic agent
• multiple factors interplay to disturb the
mechanism that maintains the balance b/n
contraction & relaxation of bronchial smooth
muscle:
 Autonomic
 Immunologic
 Endocrine
 infectious factors interplay
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 Pathophysiology
• the airway inflammation results from d/t
chemical mediators
• mediators are released from local mast cell
through:
 Ig E mediated specific allergens
 Non- specific stimulation

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 Mediators & their effects
1. Early phase (10 to 30 minutes)
 preformed mast cell products such as
Histamine, leukotrines, etc. produce :
 bronchoconstriction
 excessive mucus production &
 mucosal edema

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 Mediators & their effects

2. Late phase ( after 6 hrs.)

 local infiltration with eosinophils,
lymphocytes & neutrophils
 there will be synthesis of mediators from
prostaglandins
 mediators will result in worsening of the
obstruction & hyper responsiveness

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 The airway obstruction & hypoxia is more
pronounced in children. Why?
• small size of airways
• Abundant mucus glands
• Soft & easily deformable ribcage
• poor collateral ventilation of the alveoli

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 The following information is needed
before initiation of the treatment
 Establishing the Dx
 Identify the triggering factors
 Assess the degree of severity

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 Establishing the Dx

Hx:
 recurrent acute or insidious onset of cough &
wheezing, typically worsening at night &
 triggered by URTI
 pts. may show spontaneous improvement or
rapid response to therapy
 Pts. may have family Hx of asthma
P/E: varying degree of resp. distress & wheeze
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 .

Few pts. may have atypical presentation such as:

 persistent cough with no wheezes
 Wheezing with no cough
 isolated tachypnea with no cough

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 Assess degree of severity using the
following signs:
• Breathlessness
• Speaking
• Level of consciousness
• RR
• Use of Accessory muscle
• Wheezing
• PR
 Based on these asthma can be classified as
1. Mild Asthma
2. Moderate Asthma
3. Severe Asthma 13
 Mild Asthma
• breathlessness: occur on walking, pts. can lie
down
• speaking: phrases
• Level of consciousness: may be agitated
• RR is increased
• No accessory muscle use
• moderate wheezing
• PR is increased
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 Moderate Asthma
• breathlessness: occur on talking, pts. Prefer to
sit up
• speaking: part of phrases
• Level of consciousness: usually agitated
• RR is increased
• usually use accessory muscle
• strong wheezing
• PR is increased
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 Severe Asthma
• breathlessness: occur on lying down
• speaking: words
• Level of consciousness: always agitated
• RR is increased
• usually use accessory muscle
• Very strong wheezing
• PR is increased

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 Imminent Arrest
• cannot speak
• sleepy or confused
• paradoxical movement of the chest
• bradycardia

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 Triggering Factors
• URTI
• Tobacco smoke exposure
• Change in climate
• Exercise
• Drugs (e.g. ASA)
• Chemicals ( e.g. malthion insecticide)

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 DDx
 Pneumonia
 Bronchiolitis
 CHF
 Foreign body aspiration
 Tuberculosis

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 Dx
• mainly clinical
• laboratory investigation is limited
• microscopic examination of sputum shows
eosinophilia
• chest X-ray is not routinely done unless there
is suspicion of associated pneumonia or ccx
like atelectasis

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 Management
Management of acute asthma:
• The objective of the Rx are:
 prevent death
 restore best level of activity & optimal lung
function
 prevent relapse by Rx of inflammation

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 Principles of treatment
• 1st determine the severity of the attack
• Give best treatment available
• Close follow up: of the response of the
emergency drugs

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Management of mild to moderate attack of
Asthma
• Epinephrine 0.1mg/kg is given
subcutaneously at interval of 20 min 3 times
• reliefs the bronchospasm rapidly in majority
of the cases
Disadvantages of Epinephrine:
o short duration of action
o tachycardia

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Management of mild to moderate attack of
Asthma
• if pt. shows complete response, send home
with long acting beta adrenergic drug:-
Salbutamol 0.1mg/kg p.o on TID base
• low dose of prednisolone for 5-7 days: helps
for rapid resolution of inflammation & reduce
relapse

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 Admission Criteria
• no response or incomplete response to
adrenaline
• status asthmaticus: progressive RD despite
administration of the usually effective drugs
• severe attack on presentation

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 Principles of Rx
 intranasal oxygen
 Aminophyline 4mg/kg i.v over 20 min QID
 Hydrocortisone 4-6mg/kg i.v QID for 2-3 days
 Start Salbutamol when the pt. becomes stable
 Treat & prevent dehydration

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 Long term management
Objectives of Rx include:
 To reduce or avoid acute attack
 To reduce limitation of activity
Principle of Rx:
• Avoid allergens
• use bronchodilators according to the need
• Give anti-inflammatory therapy in selected cases
• Salbutamol 0.1mg/kg TID
• Prednisolone 2mg/kg/ day
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