Bronchial asthma

Introduction
 Asthma

is a common medical problem and its prevalence is increasing  The morbidity and mortality is significant if not treated adequately

Definition
A

chronic inflammatory disease of the airways  characterized by oedema, infiltration with inflammatory cells especially eosinophils, hypertrophy of glands and smooth muscle and damaged epithelium.  Hyperresponsiveness  airways narrow easily in response to a wide range of stimuli.

 Wheezing,

SOB, chest tightness and coughing particularly in the night or in early morning

Epidemiology
 An

estimated 4-5% of the population is 4affected around the world  All ages but predominant in early life.  About 50% of cases develop before age of 10 and another 30% occur before age of 40.  In childhood,there is 2:1 male/female preponderance, but the ratio equalizes by age 30

Triggering stimuli
        

Allergens ( house dust mites, domestic pets, pollen) Aerosol chemical Atmospheric pollution. Changes in temperature Drugs( Aspirin, beta blockers) Exercise Respiratory infection Emotional stress Smoke

Pathophysiology
 Chronic inflamed

airways become obstructed and airflow is limited mucous plugs and increase inflammation when expose to risk factors

 Bronchoconstriction,

Clinical features
 Wheezing  H/o

cough worse particularly at night - Recurrent wheeze, diff breathing and chest tightness  Sx worsen at night awakening pt/ seasonal pattern or + risk factor  Eczema, hay fever, F/H of asthma or disease  Responds to anti asthma therapy

A typical asthma patient..

 

Tachypnea, tacchycardia and mild systolic hypertension. Expiration is prolonged

Typical symptoms  At the end of the episode cough becomes productive of thick ,stringy mucus, which often takes the form of casts of the distal airways (Cruschmanns spirals).

Differential diagnosis
 Upper

airway obstruction by tumour or laryngeal edema  Acute left ventricular failure  Carcinoid tumours  Recurrant pulmonary embolism  Chronic bronchitis  Eosinophilic pneumonias.

Diagnosis
Demonstration of reversible airway disease  Greater than 15% increase of FEV after two puffs of FEV -adrenergic agonist.  Demonstration of hightened airway responsiveness to challenges with histamine, methacholine or hyperventilation of cold air  PEFRs to measure response to therapy  Sputum examination for charcot-Layden crystals and charcoteosinophilia  Blood eosinophilia

Diagnosis
   

Chest X ray- Non specific,hyperinflated lungs rayspecific,hyperinflated Measurement of serum IgE levels Positive wheal-flare reaction to skin tests whealABG: Hypoxia, hypocapnia and respiratory alkalosis

Management of Bronchial asthma

Objectives:  Daytime symptoms- nil to thrice a week symptoms Night symptoms-nil symptoms Normal lifestyle and physical activity  Exacerbations-nil to mild Exacerbations Need for beta-2-agonist-nil to thrice a week beta- agonist FEV1,PEF-normal to > 90% of personal best. FEV1,PEF-

Treatment


   

Treatment of asthma depends on severity of symptoms and patients are classified for this purpose as 1)Mild intermittant 2)Mild persistant 3)Moderate persistant 4)Severe persistant

Table 3. GINA classification of asthma severity by clinical features before treatment

Symptoms/Day STEP 1 Intermittent < 1 x a week Asymptomatic and normal PEF between attacks
1 time

Symptoms/ Night 2 x a month

PEF or FEV1 80%

PEF variability < 20%

STEP 2 Mild Persistent

a week but < 1 time a day  Attacks may affect activity Daily Attacks affect activity Continuous Limited physical activity

2 times a month

80%

20-30%

STEP 3 Moderate Persistent STEP 4 Severe Persistent

> 1 time a week

60%-80%

> 30%

frequent

60%

> 30%

Drug treatment
1.Bronchodilators treat symptoms of asthma. used as required rather than regularly. asthma is severe and difficult to control, taken on regular basis. 3 main groups of bronchodilators:  Beta2 agonists  Anticholinergics  Methylxanthines

a. Beta2 agonists  most effective  safe drugs with few side effects when taken by inhalation  side effects are tremors and tachycardia  Oral slow release preparations and inhaled long acting beta2 agonists such as Salmeterol /bambuterol are useful for nocturnal asthma.

Inhaled beta2 agonist: salbutamol (Ventolin, Respolin) terbutaline (Bricanyl) fenoterol (Berotec) salmeterol (Serevent) - long acting  Oral long acting beta2 agonist: salbutamol (Volmax) terbutaline (Bricanyl durules) bambuterol (Bambec)


Oral short acting beta2 agonist: salbutamol terbutaline

b. Anticholinergic drugs Route: Inhalation -lower onset asthma longer duration of action. very few side effects. Examples: Ipratropium bromide (Atrovent)

c. Methylxanthines  oral and parenteral  Sustained release preparations may be useful in nocturnal asthma. Examples: Nuelin SR, Theodur, Euphylline  Note: Inhaled beta2 agonists are the bronchodilator of choice.

2. Anti-Inflammatory Drug A. Corticosteroids  main prophylactic drugs.  Route:Inhalation  dosage should be kept to a minimum to reduce side effects (usually local side effects).  Oral steroids maybe required for severe chronic asthma. Examples: Beclomethasone dipropionate Budesonide (Pulmicort)

B. Sodium cromoglycate (Intal)  very safe with no significant side effects.  Route: inhalation (power Spinhaler or metered dose inhaler). It is of greatest benefit in young, atopic patients. Other treatments  Anti-histamines :ketotifen proven to be of limited efficacy in Antimany clinical trials in asthma

Treatment
STEP 1 MANAGEMENT: MANAGEMENT:  No need for any long term daily medication  Use short acting inhaled beta-2 agonist for quick betarelief as necessary.  Teach about basic facts of asthma and inhaler technique and the role of medications

STEP 2 MANAGEMENT  Step 1 +Low dose inhaled steroid.  e.g. beclomethasone or budesonide 2puff BD or sodium chromoglycate  For quick relief use a short acting inhaled bets-2betsagonist as necessary  Teach self monitoring of asthma

STEP 3 MANAGEMENT  Daily long term control medications  either medium or low dose inhaled steroid + long acting beta-2-agonist / tablet / sustained betaT.theophylline  For quick relief inhaled short acting beta2- agonist beta as often as necessary  Educate about step 1 and step 2 actions

Step 4 management  Step 3+oral corticosteroids  Quick relief medications :Salbutamol :Salbutamol

STEP UP and STEP DOWN

Step up: asthma control is not maintained, going up to the next treatment level after reviewing medication technique, adherence and environmental control Step down: reviewing symptoms every 1-6 months 1and a gradual step-wise reduction in steptreatment may be possible

Management Of Chronic Asthma In Adults

3030-60 mg of prednisolone immediately  tapered down and stopped within 7-14 days. 7Indications :  symptoms and peak expiratory flow (PEF) get progressively worse day by day.  PEF <60%  Sleep disturbed  morning symptoms persist until midday.  diminishing response to inhaled bronchodilators.  required emergency Rx with neb or injected bronchodilators
 

Assessment of severity of asthma

  

History taking Physical examination PEF measurement

Features of moderately severe asthma  normal speech  pulse rate < 110/min  respiratory rate < 25 breaths/min  PEF > 50% predicted or best value

Features of acute severe asthma  too breathless to complete sentences in one breath  respiratory rate 25 breaths/min  pulse rate 110/min  PEF 50% predicted or best value

Life threatening features:  central cyanosis  feeble respiratory effort  silent chest on auscultation  bradycardia or hypotension  exhaustion  confusion or unconsciousness  PEF < 33% predicted or best value /(<150 l/min of patients who are not able to blow)

  

ABG (normal or high PaCO2 ) severe hypoxaemia: PaO2 < 60 mmHg irrespective of treatment with oxygen a low pH

Management Of Acute Asthma

1. PEF > 75% (Mild acute asthma) :  inhaled bronchodilator (e.g. salbutamol, terbutaline or fenoterol) from MDI  Observe for 60 minutes  stable and PEF still >75%  discharge.

2. Initial PEF < 75% A. Immediate  high concentration oxygen (>40%) in cases with initial PEF <50%  salbutamol 5mg or terbutaline 5mg or fenoterol 5mg via nebuliser driven by oxygen.

*Salbutamol 2-5mg, i.e. 20-50 puffs, 5 puffs at a time 220via pressurised aerosol inhaler into a large spacer device *Add ipratropium bromide 0.5mg to nebulised beta2 agonist for patients with acute severe asthma.

 

T. Prednisolone 30-60mg OD 30Very ill patients should be given IV hydrocortisone 200mg stat.

 Sedatives should not be  Antibiotics  chest x-ray if x-

prescribed.

pneumothorax or pneumonia or features of acute severe or life threatening asthma

B. Life threatening features are present:  IV aminophylline 250mg slowly over 20 minutes  or IV terbutaline or salbutamol 250mcg over 10 minutes.  Bolus aminophylline should not be given to patients already taking oral theophylline.

3. Subsequent Management In The Ward Or ICU  Continue O2 at 40%  IV hydrocortisone 200mg 6-hourly or T.prednisolone 63030-60mg OD  neb beta2-agonist 4-hourly or up to every 15-30 min beta2415 add ipratropium bromide 0.5mg to neb beta2-agonist beta2and repeat 6-hourly if patient not improving. 6-

still not improving  aminophylline infusion (0.5-0.9mg/kg/hour); monitor (0.5blood levels (where facility is available) if continued for more than 24 hours.  *terbutaline or salbutamol infusion 3-20mcg/min 3after an initial IV bolus dose of 250mcg over 10 min.

Monitoring  Repeat PEF 15-30 min after starting treatment. 15 Maintain ABG SPo2 > 92%

During acute exarcerbation..

        

Neb Combivent/ AVN 2:2:2 STAT then 4hrly Oxygen NP 3L/min IV hydrocortisone 200mg STAT then 100mg QID Oral Prednisolone 30mg OD for 5/7 T.neulin SR 250mg BD Syp Benadryl 15ml tds T.Bisolvan 8mg tds T.EES 800mg BD T.Augmentin 625mg BD

   

Pre and Post Neb PEFR MDI Salbutamol 2Puff PRN MDI Beclomethasone 2Puff BD Refer Phamarcist for MDI technique

Severe asthma attack

   

ABG IV MgSO4 2g in 20cc NS/30mins IV Salbutamol 5mg in 500cc NS and infusion 3ml/hr KIV intubation

Thank You