ASTHMA & COPD

ASTHMA
Exacerbating factors

Acute Severe Asthma

B-blockers
Can cause bronchospasm
Especially non-cardioselective e.g
propranolol, timolol
Give prostaglandin analogue instead
e.g. bimatoprost, travoprost
NSAIDS
Can cause bronchospasm in those
sensitive
Aspirin sensitivity affects 5-20% of
asthma patients
Use clopidogrel instead

STEP 1 - B2
agonist

intermittent

STEP 2 +
steroid

>3 attack/wk
awake from
sleep 1/wk
exacerbations of
asthma in the
last 2 yrs

PEF 33-50% of best

Cant complete sentences in one breath
Resp rate >= 25/min
Pulse >= 110/min

Life-threatening features

STEP 3 +
LABA/ LRA/
Xanthines

affects activity
>1 attack/day

PEF <33% of best or predicted

O2 saturation<92%
Silent chest, cyanosis or feeble respiratory
effort
Arrhythmia or hypotension
Exhaustion or altered consciousness

STEP 4 High
ISteroid +
LRA/
Xanthines
continuoud Sx
limites activity
Frequent
Exacerbations/h
ospitalisation

STEP 5 oral steroid

freq emergency
care
not adequately
controlled

ASTHMA & COPD

COPD

Stable COPD
1.
2.
3.

General: SABA + SAAM

Mild/Moderate: LABA + LAAM
Severe: LABA + corticosteroid (budesonide)

Infective exacerbations
S - Salbutamol
I Ipratropium
H Hydrocortisone
P Prednisolone
A Amoxicillin

Figure 1 MANAGEMENT OF INFECTIVE EXACERBATIONS OF

COPD

ASTHMA & COPD

Targeting immedicate phase bronchospasm

Bronchodilators
B2 agonists
Muscarinic antagonists
Xanthines

Targeting late phase inflammation

Anti-inflammatory

Glucocorticoids
Leukotriene antagonists
5-Lipoxygenase Inhibitor
Mast cell stabilisers
MODE OF ACTION

LA B2
agonist

SA B2
agonist

ASTHMA
SALBUTAMOL

Act on beta2 adrenergic receptor

Cause smooth muscle relaxation

Salmeterol

INDICATIONS

ADVERSE EFFECTS

occasional
for symptom relief
If more than once daily or at night? go to
step 2

Tremor, anxiety, headache, muscle cramps,

dry mouth, and palpitation. allergic reactions
of paradoxical bronchospasm, urticaria,
angioedema, hypotension, and collapse

Maintenance and prevention of asthma

maintenance of (COPD) symptoms.

Some benefit but not enough? Increase

steroid dose.

dizziness, sinus infection, and migraine

headaches

AntiMuscarinic

No benefit? stop.
IPRATROPIUM
Tiotropium

Cholinergic antagonists. Block the vagally

mediated contraction of airway smooth
muscle and mucus secretion. Not well
absorbed

Xanthine

Theophylline

Inhibits phosphodiesterase to raise

intracellular cAMP.
Reduces inflammation and innate
immunity
Reverse steroid insensitivity

Blurred vision
Dry mouth
Urinary retention
Glaucoma

Not as effective unless with presence of COPD

Pt that unable to tolerate adrenergic agonists.

Narrow therapeutic window, high side effect

profile.

GI: Nausea, Diarrhoea

Tachycardia
Cardiac Arrhythmias
o/dose may cause seizure or fatal
arrhythmias

Corticosteroid

ASTHMA & COPD

Beclometasone
(Inhaled)
Budesonide COPD
Fluticasone
Hydrocortisone
(IV)

Leukotrie
ne RAg

Prednisolone
(Oral)

Montelukast

ICS do not directly affect the airway smooth

muscle. Instead, ICS therapy directly targets
underlying airway inflammation by decreasing
the inflammatory cascade, reversing mucosal
oedema, decreasing the permeability of
capillaries, and inhibiting the release of
leukotrines
Reduce inflammation and mucus
production
Irreversibly binds with glucocorticoid
receptors. Inhibition of gene transcription
for COX2, cytokines, cell adhesion
molecules, and inducible NO synthase
Blockage of Vit D3-mediated induction of
osteocalcin gene in osteoblast
Modification of collegenase gene
transcription
Block the effect of cysteinyl leukotrines.

Second step asthma (beclomethasone)

Budesonide (Severe COPD)

Severe exacerbation of asthma.

Asthma in children 6 months of age.

Prophylaxis of asthma.
Prevention of exercise-induced
bronchospasm

Oral candida, Hoarseness

Bruising
Increased appetite/Weight gain
Osteoporosis
Cataracts
Mood changes, Difficulty sleeping
Glucose intolerance
Cushings syndrome
Increased incidence of LRTIs in elderly

Gi disturbances. Elevations in serum hepatic

enzymes. Churg-Strauss syndrome. Headache
dyspepsia.

ASTHMA & COPD