BRONCHIAL ASTHMA

GROUP MEMBERS
Shathish a/l Thendayuthapani
012012100088
Evelyn Syarmala a/p Paul Raj
012012100022
Rames a/l Poonudurai

012013050217

DEFINITION

PATHOPHYSIOLOGY

TRIGGER FACTORS

CLINICAL FEATURES

DIAGNOSIS

SHATHISH A/L THENDAYUTHAPANI

012012100088

DEFINITION
Asthma is defined as a chronic inflammatory disorder of the
airways in which many cells and cellular elements play a role.
In susceptible individuals this inflammation causes recurrent
episodes of wheezing, breathlessness, chest tightness and
coughing particularly at night or early in the early morning.
These episodes are usually associated with widespread but
variable airflow obstruction that is often reversible either
spontaneously or with treatment.
Asthma is a common and potentially fatal disorder.

PATHOPHYSIOLOGY

TRIGGER FACTORS
A

allergens pollens, animal dander, dust mites, mould

bronchial infection

cold air, exercise

drugs aspirin, NSAIDs, -blockers

emotion stress, laughter

food sodium metabisulphate, seafood, nuts

gastro-esophageal reflux

hormones pregnancy, menstruation

irritants smoke, perfumes, smells

job wood dust, flour dust, isocynates

CLINICAL FEATURES
The principal symptoms of asthma are :wheezing attacks
chest tightness
breathlessness
cough
Nocturnal symptoms ( usually worst during the night)
Note: Asthma should be suspected in
children with recurrent nocturnal cough & in
people with intermittent dyspnoea or chest
tightness, especially after exercise.

DIAGNOSIS
The diagnosis of asthma is predominantly clinical & based on
a characteristic history.
Supportive evidence is provided by the demonstration of
variable airflow obstruction.
Clinical history compatible with asthma plus either/or :

FEV1 15% increase following administration of a

bronchodilator/ trial of corticosteroids (Prednisolone 30mg
daily for 2 weeks)

> 20% diurnal variation on 3 days in a week for 2 weeks

on PEF diary

FEV1 15% decrease after 6 mins of exercise

REFERENCES
Davidsons Principles and Practice of Medicine,
22nd Edition
MURTAGHS GENERAL PRACTICE, 5th Edition,
Mcgraw HILL
www.emedicine.medscape.com

CHRONIC ASTHMA
EVELYN SYARMALA A/P
PAUL RAJ
012012100022

CONTENTS
Assessment of asthma
severity
Non-pharmacological
treatment
Pharmacological treatment

Severity/Grade

Status before treatment

Intermittent

Mild persistent

Symptoms > weekly, not

everyday
Night symptoms >2/month
Symptoms regularly with
exercise

80 %

Moderate
persistent

Symptoms everyday
Night symptoms > weekly
Several known triggers apart
from exercise

60-80%

Severe persistent

Symptoms everyday
Wakes frequently at night
with cough/wheeze
Chest tightness on waking

< 60%

Episodic
Symptoms < weekly
Night symptoms > 2/month
Mild occasional symptoms
with exercise

Lung function
FEV1 or PEFR ( %
predicted)
80 %

Non-pharmacological
treatment
1) Reduce exposure to the allergens
- Dust mites/Carpets/Pollen from flowers/trees
- Animal fur
- Food
- Environment (open burning/haze)
- Chemicals (paint/aerosol/spray)
- Emotional factors (stress/fear)
2) Avoid strenuous physical activity
3) Smoking cessation advice
4) Occupational asthma
5) Proper technique of using inhaler

Pharmacological
treatment
Types and classification of asthma
medication
- Reliever
- Preventer
- Controller
Step up & step down management

Simple Classification
Reliever : bronchodilator
Preventer : anti-inflammatory
Symptom controller : long-acting 2
agonist

Reliever
The three groups of bronchodilators are :
- 2-agonists Salbutamol, Terbutaline,
Salmeterol, Formoterol
- Anticholinergics Ipratropium bromide
(Atrovent),
Tiotropium
- Methylxanthines Theophylline,
Aminophylline
- Omalizumab ( anti-IgE agent)

2-agonists
Examples : Salbutamol, Terbutaline ( short-acting)
Salmeterol, Formoterol ( long- acting)
Stimulate the 2 adrenoreceptors and thus relax
bronchial smooth muscle.
Preferred route of administration : Inhaled
Vehicles of administration : MDI, inhalation, a dry
powder, nebulisation
Inhaled drugs cause bronchodilation in 1-2 minutes
Peak effects by 10-20 minutes
Adverse effects : Headache,palpitation,hypokalemia,
tachycardia

Anticholinergics ( Muscarinic receptor antagonist)

Examples : Ipratropium bromide (Atrovent),
Tiotropium
Blocks the muscarinic acetylcholine receptors in the smooth
muscles of the bronchi in the lungs, opening the bronchi.
Vehicles of administration : nebulising solution, MDI
Adverse effects : Dry mouth, glaucoma
Methylxanthines
Examples : Theophylline, Aminophylline
Inhibits phosphodiesterase enzymes, increase cAMP,
decrease release of mediators.
Competitive inhibition of adenosine which induces
bronchoconstriction in asthmatics, relaxes bronchial smooth
muscles.
Adverse effects : nausea, vomiting, diarrhea, muscle cramps,
palpitations

Omalizumab ( anti-IgE agent)

Subcutaneous injection in patients
less than 12 years with moderate to
severe allergic asthma treated by
inhaled corticosteroid and who have
raised serum IgE levels.
Adverse effect : Injection site
reactions
(redness, stinging,
bruising)

Preventer
Inhaled corticosteroids
- Beclomethasone
- Budesonide
- Fluticasone
Oral prednisolone
Cromolyns
- Sodium cromoglycate
- Nedocromil sodium
Others include :
- Leukotriene receptor antagonist : Montelukast,
Zafirlukast

Corticosteroids
Examples : Inhaled corticosteroids
- Beclomethasone,
- Budesonide
- Fluticasone
Usually in all asthma patients with regular persistent
symptoms even mild symptoms.
Dose range : 400-1600 mcg (adults), aim to keep below 500
mcg for children and 1000 mcg for adults.
Vehicle of administration : MDI, Turbuhaler, Accuhaler
Frequency : once or twice daily
Adverse effects : oropharyngeal candidiasis, dysphonia,cough
NOTE: Rinse mouth with water and spit out after using inhaled
steroids.

Oral prednisolone
Mainly for exacerbations
Given with the usual inhaled
corticosteroid and bronchodilators.
Dose : up to 1 mg/kg/day for 1 to 2
weeks
Adverse effects : minimal if used for
short period of time
Long term use osteoporosis, glucose
intolerance, adrenal suppresion, thinning
of skin, easy bruising

Cromolyns
Examples : - Sodium cromoglycate
- Nedocromil sodium
Vehicle of administration :
Sodium cromoglycate dry capsule for inhalation,
metered dose aerosols, nebuliser solution.
Adverse effects : uncommon, local irritation by dry
powder
Nedocromil is used for frequent episodic asthma in
children over 2 years of age for prevention of
exercise-induced asthma & mild to moderate asthma
in some adults.
Initial dose : 2 inhalations qid
Adverse effects : uncommon

Leukotriene receptor
antagonist
Examples : Montelukast, Zafirlukast
For seasonal asthma & aspirinsensitive asthma, reduce the need
for inhaled steroids or alternative if
cannot tolerate ICS or trouble using
an inhaler.
Montelukast is given as 5 or 10 mg
chewable tablet once daily.

STEP WISE
APPROACH

STEP 1: Mild Intermittent Asthma

Inhaled short-acting 2 agonist as
required
Salbutamol, terbutaline

STEP 2: Regular preventer therapy

Add inhaled steroid, 200-800 g/day
400g/day is an appropriate starting
dose for many patients
Start at dose of inhaled steroid
appropriate to severity of disease

STEP 3: Initial add-on therapy

Poorly controlled despite regular use of ICS.
1.Inhaled long-acting -agonist (LABA)
- Improve asthma control
- Reduce the frequency & severity of exacerbations
when
compared to increasing the dose of ICS alone.
Good response to LABA continue LABA
Benefit from LABA but control still inadequate
continue LABA and increase steroid dose to
800g/day (if not already on this dose)
No response to LABA stop LABA and increase
inhaled steroid to 800g/day. If control still
inadequate, institute trial of other therapies,
leukotriene receptor antagonist or theophylline

 STEP 4: Persistent poor control

Increasing inhaled steroid up to 2000
g/day
Oral therapy with leukotriene receptor
antagonist, theophylline, slow release
2 -agonist tablet may be considered.

 STEP 5: Continuous or frequent use of

oral steroid
Use daily steroid tablet (prednisolone)
in the lowest amount necessary to
control symptoms.
Maintain high dose inhaled steroid at
2000g/day
Consider other tablets to minimize the
use of steroid tablets
Refer patients for specialist care

STEP DOWN
Once asthma control is established,
the dose of inhaled (or oral)
corticosteroid should be titrated to
the lowest dose at which effective
control of asthma is maintained.
Decreasing the dose of ICS by around
2550% every 3 months is a
reasonable strategy for most patients.

REFERENCES
MURTAGHS GENERAL PRACTICE, 5th
Edition, Mcgraw HILL
Davidsons Principles and Practice of
Medicine, 22nd Edition

THANK YOU

ACUTE ASTHMA-ASSESMENT
ACUTE ASTHMA-TREATMENT
ROLES OF TABLET
PREDNISOLONE,TABLET
SALBUTAMOL & LABA
RAMES A/L K.POONUDURAI
012013050217

ACUTE ASTHMA
Worsening of the course of asthma characterized by
increasing symptoms, deterioration in PEF, and increase in
airway inflammation.

Most attacks occurs gradually (several hours to days)

Various clinical signs and symptoms used to differentiate the
severity

Should be differentiated with poor asthma control that is

usually present with diurnal variability

Causes for acute asthma exacerbations:

Viral infections
Domestic or occupational allergens (house dust
mite, pollens, pet dander)
Allergen or pollutant exposure
Cessation or reduction of medication
Concomitant medication, (e.g non-selective
beta blockers)
Weather
Strenuous exercise

Assessment of acute
asthma
High risk patient:
1. Previous severe asthma attack requiring intubation and
ventilation
2. Hospitalization/ Emergency care for asthma in last 12
months
3. Currently not using ICS/ Poor adherence to ICS
4. Long term oral steroid treatment
5. Carelessness with taking medications
6. Night time attacks, especially with severe chest tightness
7. Recent emotional problem
8. Frequent use of SABA, especially for more than 1 month

Early warning signs of acute asthma attack:

1. Symptoms persisting or getting worse despite
adequate medication
2. Increased cough/chest tightness
3. Poor response to 2 inhalations
4. Benefits from inhalations not lasting 2 hours
5. Increasing medication requirements
6. Sleep disturbance by cough, wheezing,
breathlessness
7. Chest tightness on waking up in the morning
8. Low PEFR readings

Dangerous signs of acute asthma attack

1. Marked breathlessness (especially at rest)
2. Extreme sleep disturbance
3. Difficulty speaking ( unable to say more than
a few words)
4. Exhaustion, drowsiness, confusion
5. Silent chest
6. Cyanosis
7. Chest retraction
8. Increased respiratory rate & pulse rate
9. Peak flow <100L/min or <40% predicted
FEV1
10.SPo2 <90%

HISTORY
Assessment of medical history should address:
1. Frequency and severity of recent symptoms,
Rapidity of onset
2. Characteristic of symptoms
3. Distinguish daytime and nocturnal symptoms
frequency
4. History of past/present smoking
5. Activities, acute illness, environmental exposure,
exposure to allergens, psychological stress, use of
NSAIDs that may trigger episodes
6. Family history of asthma/ atopic disease
7. Detailed occupational history
8. Effects of inhalers (if patient is on medication)

8. amount of inhaled -agonist selfadministered during the exacerbation

9. Whether symptoms are attributable to
asthma
10. Identify is patient is at risk for serious
morbidity and mortality from asthma

1.
2.
3.
4.
5.
6.
7.

PHYSICAL EXAMINATION
General appearance of patient, Difficulty in
talking
Vital signs- Heart rate, respiratory rate, Blood
pressure
Audible wheeze
Nasal flaring, pursed lips, central cyanosis,
Hyperinflation of chest, use of accessory
muscles, tracheal tug
Prolonged expiratory phase, expiratory wheezing
Altered mental status, confusion
Examine for signs of other possible diagnosis (eg
Pneumonia/ pneumothorax)

1.
2.
3.

4.
5.
6.

INVESTIGATIONS
Pulmonary function test- PEFR, Spirometry
Measurement of oxygen saturation by pulse
oximetry- To assess ventilaton status
Arterial blood gas analysis- For patients with
low oxygen saturation on room air, or the
patient who does not respond to initial
treatment with FEV1 remaining less than 30%
Chest X-ray (To rule out upper airway causes of
obstruction, suspicion of pneumonia or
pneumothorax)
Serum potassium concentration
Full blood count, ECG, microbiological
investigation (if required)

MANAGEMENT OF
ACUTE ASTHMA
ATTACK

Management of Acute severe Asthma

1. Continuous assessment of patient
2. Oxygen 40-60%
3. Monitoring of PEFR, Oxygen saturation
4. Administer repeat salbutamol 5mg with
ipratropium bromide 500ug by nebulizer
5. Hydrocortisone 200mg IV 4 hourly for 24
hours
6. Prednisolone continued at 60mg orally
daily for 2 weeks
7. Arterial blood gas measurement (if
PaCO2 increased, patient may need
ventilation)

8. Chest X-ray to exclude pneumothorax

9. If no improvement, IV MgSO4 1.2-2.0g
over 20 minutes or aminophylline 5mg/kg
loading dose over 20 minutes followed by
continuous infusion at 1mg/kg/hour
10. If no improvement, transfer to ICU

Follow Up after an Exacerbation

Patients must be followed up until symptoms and
lung function test return to normal.
Review on:
a. Patientss understanding of the cause of
exacerbation
b. Modifiable risk factors of exacerbations
c. Understanding of purpose of medications, and
inhaler technique skills
d. Review and revise written asthma action plan
e. Discuss medication use and adherence to ICS
and OCS

ROLES OF TABLET
PREDNISOLONE, TABLET
SALBUTAMOL, LABA

Tablet Prednisolone

1. Used mainly for exacerbations

2. Given with the usual inhaled corticosteroids and
bronchodilators
Rescue causes of oral steroids:
3. To control exacerbations of asthma
4. Worsening of symptoms and PEF
5. Onset or worsening of sleep disturbance by
asthma
6. Morning symptoms persist till midday
7. Diminishing response to inhaled bronchodilators

Dose
Up to 1mg/kg/day for 1-2 weeks (30-60 mg daily)
Action and Use
Short term treatment (5-7 days) is important
early in the treatment of severe acute
exacerbations, with main effects seen after 4-6
hours. Tapering required if treatment given for
more than 2 weeks.
Side effects
Osteoporosis, glucose intolerance, adrenal
suppression and easy bruising with long-term
use

Tablet Salbutamol
A type of selective beta 2 agonist drug
Oral administration rarely required and not
recommended
Inhaled drugs produce measureable
bronchodilation in 1-2 minutes and peak effects
by 10-20 minutes

Long Acting Beta-2 Agonist (LABA)

Examples: Salmeterol, Formoterol
Effects last for 12 hours or more
Uses:
Used on daily basis to control moderate and severe
persistent asthma
Always used as an addition with inhaled
corticosteroids
Used as metered dose or dry powder inhaler
Enhance the corticosteroids' anti-inflammatory
action for controlling asthma and
preventingasthma attack

Combinations of long acting beta-2 agonist and

inhaled corticosteroids
Generic Name

Brand Name

Formeterol and
budesonide

Symbicort

Formoterol and
mometasone

Dulera

Salmeterol and
fluticasone

Advair

REFERENCES
Murtaghs General Practise 5th Edition
Davidsons Principles of Medicine 22nd

Edition
www.ginasthma.org
www.emedicine.medscape.com
www.asthmapartners.org
South African Medical Journal (SAMJ)

WHAT PATIENT SHOULD DO WHEN HAVING ASTHMA

ATTACK AT HOME ?