BRONCHIAL ASTHMA

DR. HUSSEIN ALMEAMAR

MBChB, MSc, MRCP (UK)

Definition :

Chronic inflammatory disorder of the airways characterized

by recurrent episodes of wheezing, breathlessness, chest
tightness and coughing, particularly at night and in the
early morning.

Prevalence:

age 13-14 --> 9-13%

Prevalence:

currently affects 235 million people (WHO)

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pathophysiology:

The pathophysiology of asthma is complex and involves

the following components:

Airway inflammation

Intermittent airflow obstruction

Bronchial hyper-responsiveness

pathophysiology:
Airway inflammation:
The inflammatory response includes mononuclear cell and
eosinophil infiltration, mucus hypersecretion, desquamation of the
epithelium, smooth muscle hyperplasia, and airway remodelling .

pathophysiology:

Airway hyperesponsiveness --> exaggerated

response to exogenous and endogenous stimuli.

Mechanisms --> direct stimulation of airway smooth

muscle and indirect stimulation by pharmacologically
active substances from mediator-secreting cells such as
mast cells

The degree of airway hyperesponsiveness generally

correlates with the clinical severity of asthma.
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Aetiology:
Theories

Genetic
e.g. ADAM 33
on chromosome
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Environment
e.g. the hygiene
hypothesis

Triggers and causes:

clinical features:

The principal symptoms of asthma are wheezing attacks,

chest tightness, breathlessness and cough.

Nocturnal Symptoms (usually worst during the night) -->

highest between the hours of 4:00 am and 6:00 am

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Investigations:
Lung function tests

Spirometry and Peak expiratory flow rate (PEFR).

Spirometry : measure FEV and VC to identifies the

obstructive defect, severity and demonstration of
bronchodilators reversibility. A reduced ratio of
FEV1 to FVC, when compared with predicted
values, demonstrates the presence of airway
obstruction.

PEF important in demonstrating the variable air

flow limitation that characterises the disease (on
waking,before and after bronchodilator and before
bed.

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Investigations:
The diurnal variation in PEFR
is a good measure of asthma
activity, assessing severity
and response to treatment.

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Diagnosis:

The diagnosis of asthma is predominantly clinical and

based on a characteristic history.
Supportive evidence is provided by the demonstration
of variable airflow obstruction.

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Diagnosis:
Clinical history compatible with asthma plus
either/or :

FEV1 15% increase following administration

of a bronchodilator/trial of corticosteroids
(Prednisolone 30 mg daily for 2 weeks
Reversibility test

> 20% diurnal variation on 3 days in a week

for 2 week on PEF diary

FEV1 15% decrease after 6 mins of exercise

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Other investigations:

Histamine or methacholine bronchial provocation

test

Blood and sputum tests: peripheral blood eosinophilia, sputum differential

eosinophil count of greater than 2% .

Skin tests Skin-prick tests (SPT)

Chest

X-ray to pulmonary infiltrate of allergic bronchopulmony aspergilosis, to

exclude pneumothorax in acute sever asthma

MANAGEMENT:

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Diagnosis:
MANAGEMENT:

Control of extrinsic factors:

Avoid causative allergens such as pets,

moulds.

Avoid active and passive smoking

Avoid NSAIDs, B blockers.

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Type a quote here.

Daily symptoms

Occasional symptoms.
Less frequent than
daily

Johnny Appleseed

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Introduction:
MANAGEMENT:
Levels of asthma control (according to GINA):
In the past 4 weeks, has the patient had:
Daytime symptoms more than twice/week?
Any night waking due to asthma?
Reliever needed more than twice/week?
Any activity limitation due to asthma?
Uncontrolled = none of these
Partly controlled = 1-2 of these
Uncontrolled = 3-4 of these
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Medications:
Short-acting relievers Inhaled 2 agonists (e.g. salbutamol , terbutaline)
Long-acting relief/disease controllers
Inhaled long-acting 2 agonists (e.g. salmeterol, formoterol)
Inhaled corticosteroids (e.g. beclometasone, budesonide, fluticasone)
Compound inhaled salmeterol and fluticasone
Sodium cromoglycate
Leukotriene modifiers (e.g. montelukast)
Other agents with bronchodilator activity
Inhaled antimuscarinic agents (e.g. ipratropium, oxitropium)
Theophylline preparations
Oral corticosteroids (e.g. prednisolone)
Steroid-sparing agents
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Prognosis:
Medications:
2-Adrenoceptor agonists
Potent bronchodilators (relax the bronchial smooth muscle).

Eective in relieving symptoms but do little for the underlying airways

inflammation.

Short-acting agonists (SABAs) : salbutamol, terbutaline

Alone for Mildest asthmatics with intermittent attacks.

At any step, as and when required from step 1 to step 5

long-acting -adrenoceptor agonists (LABAs): salmeterol or formoterol

2

Poorly controlled asthmatics on standard doses of inhaled steroids

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Introduction:
Medications:
LABAs :

Improve symptoms and lung function and reduce exacerbations in patients.

Should never be used alone but always in combination with an inhaled corticosteroid.
Increasingly.

Ex of fixed-dose combinations with corticosteroids (LABA+ ICS)

formoterol/budesonide

salmeterol/fluticasone

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Introduction:
Medications:
Inhaled corticosteroids (ICS):
Indication: all asthma patients with regular persistent
symptoms even mild symptoms, (from step 2 upwards).

Ex: Beclometasone, budesonide, fluticasone, mometasone

and triamcinolone.

Only 10% and 25% of the ICS will reach the airways
depending on inhaler technique and aerosol device.

S.E of ICSs: oral candidiasis, and hoarseness. systemic side

eects are less likely than with oral steroids but can occur
with high-dose inhaled corticosteroids.
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Introduction:
Medications:

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Introduction:
Medications:
Antimuscarinic bronchodilators
mainly indicated during asthma exacerbations.
EX: ipratropium bromide

Leukotriene modifiers, Ex: Montelukast (Singulair)

Targets one of the principal asthma mediators by inhibiting the cysteinyl LT
receptor.
LTRAs should be tried in any patient who is not controlled on low to medium
doses of inhaled steroids.
A 4-week trial of LTRA therapy is recommended before a decision is made to
continue or stop.
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Introduction:
Is
there a new medication?
Omalizumab
Its a monoclonal antibody--> bind to IgE
Indication in asthma according to NICE:
Confirmed allergic IgE mediated asthma as an add on for patients aged 6 and above if they needed
continuous or frequent oral corticosteroids (4 or more courses in the previous year)
Most important side effects
- Local injection site side effects
- Allergy and anaphylaxis (should monitor the patient after injection and prepare anaphylaxis
medications)
Dose
According to weight and IgE level

Cost around the

1000 usd/month

- Subcutaneous injection every 2-4 weeks

Efficacy of the drug should be monitored for all patients
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Exacerbations of asthma:
During the course of asthma , patient may experience exacerbation
which characterised by increase in the symptoms and deterioration in
lung function.
Most common causes of exacerbations:

viral infections.

moulds.

pollens.

air pollution.

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Exacerbations of asthma:

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Introduction: of asthma:
Exacerbations
Management of mild to moderate exacerbations:
Short courses of rescue oral corticosteroids (prednisolone 30
60 mg daily) for two weeks are often required to regain control.
Indications for rescue courses include:
symptoms and PEF progressively worsening day by day
sleep disturbance by asthma.
diminishing response to an inhaled bronchodilator .
severe symptoms require treatment with nebulised or injected
bronchodilators.
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Management of acute severe asthma:

1. assessment of the patient.

2. Oxygen 4060% is given.

3. The PEFR, O2 saturation.

4. Administer repeat salbutamol 5 mg + ipratropium bromide 500 g

by oxygen-driven nebuliser

5. Hydrocortisone 200 mg i.v. is given 4-hourly for 24 hours.

6. Prednisolone is continued at 60 mg orally daily for 2

weeks.

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Management of acute severe asthma.

7. Arterial blood gases are measured; if the PaCO2 increased,
ventilation may be required.

8. A chest X-ray is performed to exclude pneumothorax.

9.One of the following intravenous infusions is given if no

improvement is seen:

IV magnesium sulphate 1.22.0 g over 20 mins, or

aminophylline 5 mg/kg loading dose over 20 mins followed by a
continuous infusion at 1 mg/kg/hr

10. No improvement urgent; transfer to ITU

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Prognosis:

The outcome from acute severe asthma is generally good. Death is

fortunately rare.

Although asthma often improves in children as they reach their

teens, the disease frequently returns in the 2nd, 3rd and 4th
decades.

Airways remodelling accelerates the contribute to the decline in

lung function over time.

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References:

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Thank you

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