BRONCHIAL ASTHMA Risk Factors a. Endogenous Factors - Genetic predisposition polmorphism - Atop - Air!a hperresponsi"eness - Gender - Ethnicit# $. En"ironmental Factors - %ndoor allergens - Outdoor allergens - Occupational sensiti&ers - Passi"e smoking - Respirator in'ections - O$esit# - Earl "iral in'ection - Diet "itde' (riggers o' asthma - allergens - )R(% "iral - E*ercise and hper"entilation +uid snthesis - Cold air change in osmolalit in +uid lining - ,ulphur dio*ide - Drugs -$-$lockers - $ronchoconstrict. aspirin acetlsaliclic acid $lock ccloo*genase/ - ,tress - %rritants Pathophysiology of asthma Genetic predisposition -0 air!a in+ammation-. 1gienic hpothesis (h2 "s (h3 - (h2 protecti"e immunit in ctokine $alance o Presence o' older si$lings o Earl e*posure to da care o (B. measles hep a o Rural en"ironment - (h3 more prone to BA o ,ensiti&ation to dust mites. etc4.. 5ost Common in+ammator cells in Asthma Eosinophils! Air!a in+ammation in asthma - Epithelial damage - Bm thickening - Air!a remodelling 1istopatholog o' small air!a in 'atal asthma - 5ucus plug !ith trapped in+ammator celss - Go$let cell metaplasia Air!a 1perresponsi"eness - E*cessi"e $ronchoconstriction response to multiple inhaled triggers that !ould ha"e no e6ects in normal air!as - 7inked to 're8uenc o' asthma smptoms - Direct $ronchoconstrictors 1istamine 5ethacholine - %ndirect $ronchoconstrictor o Allergens o %rritant o ,ulphur o*ide D* A. ,creening ,trategies 2. 1* o Cough !9c !orsens at night o Recurrent !hee&es o Recurrent DOB o Recurrent chest tightness 3. PE o PE ma $e normal o :hee&es are characteristic ;ndings $ut not "er speci;c 'or asthma -produced !hen air!as are constricted/ B. ,trategies 'or Con;rmation 2. ,pirometr o (o doc air+o! o$struction o Dec FE<2. FE<29F<C. PEF o A 23= -3>> m7/ impro"ement in FE<2 either spontaneousl or a'ter inhalation o' B3 agonist is considered signi;cant 3. Peak E*pirator Flo! Rate -PEFR/ o Correlates closel !9 FE<2? used as an ad@unct and not a su$stitute 'or spirometr o Better suited 'or monitoring rather than d* o PEF increases 3>= a'ter 2A-3> minutes4 B. Air!a hperresponsi"eness o 5ethacholine or histamine inhalation challenge o 3>= 'all in FE<2 'rom $aseline CCR - )suall normal $ut ma sho! hperin+ated lungs ,kin Prick test - -D/ - allergic asthma - --/ intrinsic asthma -non-atopic tpe. adult-onset/ Di6 D* 7ocali&ed - <ocal cord paresis - 7arngeal ca - (racheal ca - Bronchial ca - Foreign $odies - Bronchopulmonar dsplasia Generali&ed - COPD Bronchiectasis - O$literati"e $ronchiolitis - Cstic ;$rosis Classi!ation of Asthma - Asthma Cont"ol o REFER (O EC(EE( to !9c mani'estation o' asthma ha"e $een reduced or remo"ed $ t* - Asthma se"erit o $ased on the intensit o' t*. to achie"e good control Chronic Asthma %ntermittent Persistent Datime s* monthl !eekl dail Eocturna a!akening less than mo mo-!kl nightl Rescue B3 use less than !eekl !kl to dail se"eral times a da PEF or FE<2 0F>= o' predicted G2-F= o' predicted HG>= ... Asthma Control G%EA 3>>F and PCRAD5 3>>I Datime s*. limitations o' acti"ities. nocturnal s*. need 'or rescue9relie"er t*. lung '*n )ncontrolled i' B or more o' partl controlled is present ControlledJ none o' the 6 Partl controlledJ an GOA7,J 2. 5inimal or no s* 3. 5inimal attacks episodes or attack B. Eo emergenc "isits K. 5inimal need 'or relie"er A. Eo limits on phsical acti"ities and e*ercise G. Eearl normal lung '*n L. 5inimal or no side e6ects 'rom meds D"#gs #s$% to t& Asthma A' Cont"oll$"s - Corticosteroids most impt inhaled or sstemic - 7ong-acting $ronchodilator - (heophlline - Anti-leukotrienes - Eon-steroidal anti-in+ammator o ,odium cromoglcate -cromoln/ o Eedocromil sodium - Anti-allergic agents o Metoti'en B. Relie"ers - ,hort acting $ronchodilator %nhaled ,ABA Oral Beta3 agonsit ,hort acting theophlline - Anti-cholinergic agents o %nhaled ipratropium $romide ,hort-acting B3 agonist - (* o' choice 'or acute e*acer$ation and pret* o' e*ercise-induced asthma 5echanismsJ Rela* air!a muscle Enhance mucociliar clearance Dec "ascular permea$ilit 5oduclate mediator release 'rom mast cell and $asophils Anti-cholinergic agents - Block post-ganglionic e6erent "agal paths - Block re+e* $ronchocronstriction caused $ inhaled irritants - ,lo! action G>-I> min $e'ore peak $ronchodilation is achie"ed (heophlline - ,hould ont $e used as 2 st line therap - %nhi$its phosphodiesterase in ,5Cs - )sed 'or nocturnal asthma -,R preparation/ - E*hi$its anti-in+ammator e6ects -atopic/ %nhaled Corticosteroids - 5ainsta therap 'or persistent asthma - 5ost e6ecti"e anti-in+ammator agent in asthma - Reduces air!a in+ammation and impro"es air!a hpperresopin"eness - Reduces s* and e*acer$ation - %mpro"es lung '*n - Decreases need 'or $ronchodilator rescue ,stemic Corticosteroids - A $urst o' oral steroids -A-2> das/ ma$e used as a ma*imum therap to achie"e control o' asthma - Reser"ed 'or t* o' acute se"ere asthma - 5a AEs Com$ined 7ABA and %nhaled Corticosteroids - Greater impro"ement in the control o' s* and lung '*n among p*s !9 persistent asthma - Addtl clinical $ene;t results 'rom steroid-induced transcription o' B3 adrenoreceptor gene !9 resultant inc snthesis o' the B3 receptor protein inc eNcienc o' $oth drugs Anti-7eukotrienes - Block leukotriene snthesis $ en&me inhi$ition or inter'ere !9 leukotriene $inding receptors - 5a$e gi"en as controller drug 'or mild persistent asthma !herein inhaled corticosteroids are not in used - )sed as add-on therap 'or moderate to se"ere persistent asthma Cromones - %nh the %gE-mediated release 'rom mast cells and a cell-selecti"e and mediator-slecti"e suppressi"e e6ect on other in+ammator cells - 7ittle $ene;t in long term-control ,teroid-spacing therapies - Anti-%gE -Omali&uma$/ o Block A$ that neutrali&es circulating %gE !9out $inding to cell-$ound %gE - %mmunotherap o Eot recommended in most asthma t* guidelines (lo)al initiati*$ on asthma +(INA, Philippin$ !ons$ns#s "$po"t on asthma an% %& of mgt A!#t$ S$*$"$ Asthma - %nc chest tightness. !hee&ing and dspnea. o'ten not or poorl relie"ed $ their usual relie"er drug Re'ractor asthma - DiNcult to control despite ma*imal inhaled therap - Anti-leukotrienes - CausesJ o E*posure to high am$ient le"els o' allergens o )nidenti;ed occupational agents o ,e"ere rhinosinusitis Corticosteroid resistant asthma - Failure to respond to a high dose o' oral prednisone -K>mg9kg 'or 3 !eeks/ - Anti-%gE COPD -pre"enta$le and treata$le dse characteri&ed $ air+o! limitation that is not 'ull re"ersi$le - air+o! limitation is usuall progressi"e-asthmaJ episodic/ and associated !9 a$normal in+ammator response o' the lung to no*ious particles and gases - commonl $ut "aria$l assoc !9 dse !9 other organ sstem that can contri$ute to the c* 'eature in indi"idual p*s --- emphsema. chronic $ronchitis. small air!a dse start Pre"alence - K th leading cause o' death in ), - A th leading cause o' the death !orld!ide and !ill $e the B rd leading cause in 3>3> -:1O/ Risk 'actorsJ - Cigarette smoking - Occupational dusts and chemicals - %ndoor air pollution 'rom $iomass 'uel - Outdoor air pollution - Passi"e or second hand smoke - Genetic suscepti$ilit %n+ammator 5echanisms in COPD Cigarette acti"ate al"eolar macrophages CCC chmeokines -%7F. GRO- a. 7(F/ neutro neutrophil elastasecathepsins. matri* metalloproteins - proteases - emphsema and mucus hpersecretion CDF lmphoctes per'orins. gran&mes proteases -O*idati"e stress in COPD/ Pathogenesis Eo*ious particles and gases --host 'actors/ lung in+ammation - %m$alance in antiproteinases - O*idati"e stress - Elastase antielastase hpothesis 5C mechanism in pathophsio - %n+ammation and e*tracelluar matri* proteolsis - Cell death - %ne6ecti"e repair Pathophsio - (pical ;ndings Air+o! o$struction o Persistent reduction in FE< most tpical ;nding o Reduced FE< 2. sho!s no signi;cant response to inhaled $ronchiodilator -23 = reductionin FE<2/ o FE<29F<C red 1perin+ation o Air trapping inc R< and R<9(7C o Progressi"e hperin+ation %nc (7C ,een in late dse 1elps to compensate 'or air!a o$struction Can push the diaphragm into a +attened position Gas e*change impairment o PaO3 usu remain near normal until FE<2 is dec to A>= o Ele"ation o' PaCO3 is not e*pected until FE< is H or O 3A= o Pulmo 1PE is usu mild o Eon-uni'orm "entilation due to regional di6erences and air!a resistance o <entilatio9per'usion mismatching accounts 'or dec in PaO3 5C cause o' hpo*emia in COPD o Pathologic Changes - -hpo*emia/ Remodelling o' "essel !all. prominent intimal thickening pulmonar hpertension 7ung Parenchma - Centrilo$ular 'orm o' emphsema more 're8uentl in upper lung region in mild cases -in smokers/ - Primar mechanism im$alance o' endogenous 4 Physiologi!al - 5ucus hpersecretion - Ciliards'*n - Air+o! limitation - Pulmonar hperin+ation - Gas e*change a$normalit - Pulmonar hpertension - Corpulmonale -in R sided heart 'ailure 3ndar to a long-standing lung dse/ %rre"ersi$le - Fi$rosis and narro!ing o' air!as - 7oss o' elastic recoil due to al" destruction - Destruction o' al"eolar support that maintains patenc o' small air!as Re"ersi$le - Accumulation o' in+ammator cells. mucus. and plasma e*udate in $ronchi - ,5 contraction in peripheral air!as - 4 Syst$mi! E-$!ts - ,stemic O*idati"e stress o Atherosclerosis o 1percoagula$ilit - A$normal o' circulator ctokines o (EF !t loss o %7 G hpercoagula$ilit. inc ;$rinogen le"els o Renin-angiotensin alteration polcthemia o G5-C,F "ascular permea$ilit ,* - Chronic cough. sputum production. dspnea on e*ertion-to di6erentiate in p*s !9 heart dse/ PE - 7arge $arrel chest - Prominent accessor muscles o' respiration - 7o!. +at diaphragm - Diminished $reath sounds and distant heart sounds - Prolonged e*piration !9 generali&ed !hee&ing D& A. Detecti"e strateg ,uspect COPD in p*s !9J - 0K> rs - 1* o' e*posure - 4 B. Con;rmation - ,pirometr J FE<29F<C HL>= Post$ronchodilator responseJ FE< dec $ 23= -#/ C. Addtl. - CCR - EmphsemaJ hperin+ation !idened %C and retrosternal spaces? +attened diaphragm. inc AP dm - Chronic $ronchitisJ tram line -"ascular markings/ - Pulmo 1PEJ prominent large "essels - ABG - C( scan - Anti-trpsin de;cienc screening -Grading o' COPD ,e"erit/ Di- D& Asthma. C1F. Asthma -sensiti&ing agent/ COPD -no*ious agents/ Eos neutro.and macrophages CdK (lmpho CDF Completel re"ersi$le completel irre"ersi$le 5gt - Pre"ent dse progression - Relie"e s* - %mpro"e e*ercise capacit - %mpro"e PO7 - Pre"ent and t* complication - Pre"ent and treat e*acer$ation - Reduce mortalit - ,moking cessationJ single most e6ecti"e and cost-e6ecti"e !a to reduce risk o' de"eloping COPD and delaing its progression - B"on!ho%ilato"s - 5ainsta o' t* - Pre"ent or reduce persistent s* - E*J B3 agonists and anticholinergics 2 st line - 5eth*anthine - Com$ination therap Glucocorticosteroids - Regular t* !9 inhaled gluco is onl 'or !ith an FE<2 HA>= - Chronic use o' oral steroids in not recommended <accines - %n+uen&a "accines reduce illness and e*acer$ation in FK-FA= and pre"ents death in COPD p*s $ L>= -once a ear. $est time to administer during rain season/ - Pneumococcal "accine is recommended 'or COPD GA rs and older and in ounger COPD p*s !9 FE< HK>= -once e"er A ears/ ABCs - Recommended onl 'or t* o' in'ectious e*acer$ations and other $acterial in'ections 5ucoltics - O"erall $ene;ts are "er small Antitussi"e - Regular use is not ad"isa$le %mmunomodulator and her$al meds - Eot recommended O*gen (herap in COPD - GOA7J to inc the $aseline PaO3 to at least G> mm1g and to produce arterial O3 saturation o' at least FF-I>= %ndications 'or long term therap - PsO3 HAA mm1G or ,aO3 HFF= !9 or !9out hpercapnea - PaO3 AA>G> mm1G or ,aO3 0FI= $ut !ith e"idence o' pulmo 1PE. polcthemia -1c(0AA=/. or peripheral edema suggesting C1F Eon-pharmacologic mgt - P*mgt - Pulmo reha$ilitation - Eutrition - ,urger o Bullectom o 7ung "olume reduction o 7ung transplant Pharmacologic (* 5ildJ "accine. !hen s*J short acting $ronchodilator 5odJ D regularl long acting $ronchodilator. i' "er s* do reha$ ,e"ereJ D glucocosteroids. check i' candidates 'or O3 therap or surger -$ullectom. lung transplant/ Acute e*acer$ations - :orsening o' sta$le condtion o %nc in cough and sputum o %nc purulence o' sputum o %nc in $reathlessness !9 or !9out !hee&e o %nc hpo*emia (* - %nhaled $ronchodilator - ABCs - ,stemic glucocorticoids - O3 - 5echanical "entilator support o %n"asi"e o Eon-in"asi"e ComplicationsJ - Pneumothora*. corpulmonale. pneumonia. sleep a$normalities. giant $ullae. acute respirator 'ailure