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    Ariff Mahdzub
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    Asthma is a heterogeneous disease, usually characterized by chronic airway inflammaon. Symptoms such as wheeze, shortness of breath, chest ghtness and cough that cary over me and intensity. Eosinophils, T lymphocytes and mast cells with associated plasma exudaon, oedema, marked smooth muscle hypertrophy, mucus plugging and epithelial damage.

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    Asthma is a heterogeneous disease, usually characterized by chronic airway inflammaon. Symptoms such as wheeze, shortness of breath, chest ghtness and cough that cary over me and intensity. Eosinophils, T lymphocytes and mast cells with associated plasma exudaon, oedema, marked smooth muscle hypertrophy, mucus plugging and epithelial damage.

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    228 views39 pages

    Seminar Asthma PDF

    Uploaded by

    Ariff Mahdzub
    Asthma is a heterogeneous disease, usually characterized by chronic airway inflammaon. Symptoms such as wheeze, shortness of breath, chest ghtness and cough that cary over me and intensity. Eosinophils, T lymphocytes and mast cells with associated plasma exudaon, oedema, marked smooth muscle hypertrophy, mucus plugging and epithelial damage.

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    © All Rights Reserved
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    of 39

    ASTHMA

    Asthma is heterogeneous disease, usually


    characterized by chronic airway inamma<on.

    It is dened by the history of respiratory
    symptoms such as wheeze, shortness of
    breath, chest <ghtness and cough that cary
    over <me and intensity, together with variable
    expiratory airow limita<on

    ETIOLOGY

    Characteris<cs of asthma.
    Airow obstruc<on
    Reversible spontaneously or with treatment

    Airway hyperresponsiveness
    to a wide range of s<muli.

    Inamma<on of the bronchi


    with eosinophils, T lymphocytes and mast cells
    with associated plasma exuda<on, oedema,
    marked smooth muscle hypertrophy, mucus
    plugging and epithelial damage

    Airway inflammation

    Bronchial
    hyperresponsiveness

    Intermittent airflow
    obstruction

    Pathophysiology
    The main actors:
    1)Allergens
    2)IgE an<body
    3)Mast cell-IgE Complex
    4)Eosinophil
    5)Dendri<c cell
    6)T-helper 2
    For more understandings,
    hXps://www.youtube.com/watch?v=NNfx27io8-
    k

    Symptoms of Asthma
    Intermittent symptomatic episodes of:
    Coughing (day, night, or with exercise)
    Difficulty breathing/Shortness of breath
    Wheezing (a whistling noise)
    Chest tightness
    Trouble sleeping/ waking at night

    May be asymptomatic between attacks

    + The symptoms of asthma consist of a triad of dyspnea,


    cough, and wheezing.
    + At the onset of an aXack, pa<ents experience a sense
    of constric<on in the chest, o_en with a
    nonproduc1ve cough.
    + Respira<on becomes audibly harsh; wheezing in both
    phases of respira<on becomes prominent; expira<on
    becomes prolonged; and pa<ents frequently have
    tachypnea, tachycardia, and mild systolic
    hypertension.
    + The lungs rapidly become overinated.
    + If the aXack is severe or prolonged, there may be a loss
    of adven<<al breath sounds, and wheezing becomes
    very high pitched.
    + The accessory muscles become visibly ac<ve, and a
    paradoxical pulse o_en develops.

    Symptoms/day

    Symptoms /night FEV 1

    >/= 80%

    PEF variability

    IntermiXent

    <1 <me/week
    </= 2 <mes/
    Asymptoma<c b/ months
    w aXack

    <20%

    Mild persistent

    >1 <mes/week
    but <1 <me/day
    AXack aect
    ac<vity

    >2 <mes/months </= 80%

    20-30%

    Moderate
    persistent

    Daily
    AXack aect
    ac<vity

    >1 <mes/week

    60-80%

    >30%

    Severe
    persistent

    Con<nuous
    Limited physical
    ac<vity

    Frequent

    </= 60%

    >30%

    Signs of Asthma

    Tachypnea
    Wheeze
    Hyperinated chest
    Hyperresonant
    Diminished air entry

    ACUTE ASTHMATIC ATTACK

    Physical examina1on
    General inspec<on:
    - tachypnoeic, sign of respiratory distress, eort
    of breathing, cyanosis (life-threatening)
    Inspec<on:
    - ngers: tar staining
    - pulse rate: tachycardia and pulsus paradoxus,
    bradycardia (life-threatening)
    - used of accessory muscles or recession
    - wheezing

    Chest

    Inspection:
    - shape: hyperinflated in
    severe asthma
    - movement of chest/silent
    chest (life-threatening)
    - chest deformity:
    - recession:
    Palpation:
    - chest expension may be
    reduce (hyperinflated)/
    normal
    - apex beat: may be
    displaced
    -vocal fremitus: decrease

    Percussion:

    - may be
    hyperresonance /
    normal
    Ausculta<on:
    - breath sound:
    vesicular
    - ronchi in expiratory
    phase, may be both in
    severe asthma
    - prolonged expiratory
    phase
    -vocal resonance
    decrease / normal

    INVESTIGATION
    Non specic inves<ga<ons
    1.Full blood count- increase number eosinophil
    in peripheral blood
    2.Chest x-ray- hyperina<on of chest, to rule
    out other causes, eg: pneumothorax
    3.Skin tests- to iden<fy allergic causes

    INVESTIGATION
    Specic inves<ga<ons
    1.Respiratory func<on test- peak expiratory ow
    rate, spirometer
    2.Exercise test
    3.Trial of cor<costeroids
    4.Histamine or methacholine bronchial
    preven<on test

    PEAK EXPIRATORY FLOW RATE(PEFR)


    Pa<ents asked to take full inspira<on to total lung capacity
    and then blow out forcefully into peak ow meter.
    Repeat three <me and the best measurement is taken.
    -ve: measures expiratory ow rate in rst 2ms of expira<on
    +ve:monitor progression of disease and its treatment
    Regular measurements of PEFR:
    - on waking up
    - prior taking bronchodilator
    - before sleep

    PEAK EXPIRATORY FLOW RATE


    Asked pa<ent to take full inspira<on
    to total lung capacity and blow out
    forcefully into peak ow meter
    ADVANTAGE: monitor progression
    of asthma and treatment
    DISADVANTAGE: only measures
    expiratory ow rate

    RESULT INTERPRETATION

    80-100 %

    A reading in this zone means that your asthma is under


    reasonably good control.

    Con<nue your prescribed program of management.

    50-80 %

    Your airways are narrowing and may require extra


    treatment.
    Your symptoms can get beXer or worse depending on what
    you do, or how and when you use your prescribed
    medica<on..

    Less than 50%

    Immediate decisions and ac<ons need to be taken. Severe


    airway narrowing may be occurring.

    Take your rescue medica<ons right away

    Trials of cor<costeroids
    Prednisolone 30mg orally given for 2 weeks
    with lung func<on measured before and
    immediately a_er course
    Substan<al improvement in FEV1: indicate
    administra<on of steroid benecial to pa<ent

    Histamine or metacholine bronchial provoca<on
    test
    Indicates presence airway
    hyperresponsiveness

    ASSESMENT OF ASTHMA
    1. Asthma control
    Assess symptom control over the last 4 weeks
    Assess risk factors for poor outcomes of asthma

    2. Treatment issues
    Check inhaler technique and adherence
    Ask about side-eects
    Does the pa<ent have a wriXen asthma ac<on plan?
    What are the pa<ents aotudes and goals for their asthma?

    3. Comorbidi<es
    Think of rhinosinusi<s, GERD, obesity, obstruc<ve sleep
    apnea, depression, anxiety
    These may contribute to symptoms and poor quality of life

    GINA assessment of symptom control


    A. Symptom control
    In the past 4 weeks, has the patient had:

    Level of asthma symptom control


    Wellcontrolled

    Partly
    controlled

    Uncontrolled

    None of
    these

    1-2 of
    these

    3-4 of
    these

    Daytime asthma symptoms more


    than twice a week?
    Yesq Noq
    Any night waking due to asthma?
    Yesq Noq
    Reliever needed for symptoms*
    more than twice a week?
    Yesq Noq
    Any activity limitation due to asthma?
    Yesq Noq

    B. Risk factors for poor asthma outcomes


    Assess risk factors at diagnosis and periodically
    Global
    Initiative
    for Asthma
    Measure
    FEV
    the
    patients
    GINA
    2015 Box 2-2B
    (1/4) at start of treatment, after 3 to 6 months of treatment to record

    Assessment of risk factors for poor asthma


    outcomes
    Risk factors for exacerbations include:
    Ever intubated for asthma
    Uncontrolled asthma symptoms
    Having 1 exacerbation in last 12 months
    Low FEV1 (measure lung function at start of treatment, at 3-6 months
    to assess personal best, and periodically thereafter)
    Incorrect inhaler technique and/or poor adherence
    Smoking
    Obesity, pregnancy, blood eosinophilia

    Risk factors for fixed airflow limitation include:


    No ICS treatment, smoking, occupational exposure, mucus
    hypersecretion, blood eosinophilia

    Risk factors for medication side-effects include:


    Frequent oral steroids, high dose/potent ICS, P450 inhibitors
    GINA 2015, Box 2-2B (4/4)

    Global Initiative for Asthma

    Global Initiative for Asthma

    MANAGEMENT
    Long term management
    1. Symptom control: to achieve good control of
    symptoms and maintain normal ac<vity levels
    2. Risk reduc1on: to minimize future risk of
    exacerba<ons, xed airow limita<on and
    medica<on side-eects

    PRINCIPLES TREATMENT IN ASTHMA


    1. Asthma self management with regular
    asthma monitoring using peak ow meter
    and individual treatment plans discussed
    with each pa<ents and wriXen down.
    2. Mild cases: start with an<-inammatory
    (controller) therapy.
    3. Use short ac<ng bronchodilators
    (salbutamol, terbutaline) to relieve increasing
    symptoms.

    Ini<al controller treatment


    Indica<ons for regular low-dose ICS - any of:
    Asthma symptoms more than twice a month
    Waking due to asthma more than once a month
    Any asthma symptoms plus any risk factors for exacerba<ons

    Consider star1ng at a higher step if:


    Troublesome asthma symptoms on most days
    Waking from asthma once or more a week, especially if any risk
    factors for exacerba<ons

    If ini1al asthma presenta1on is with an exacerba1on:


    Give a short course of oral steroids and start regular controller
    treatment (e.g. high dose ICS or medium dose ICS/LABA, then
    step down)

    GINA 2015, Box 3-4 (1/2)

    A_er star<ng ini<al controller treatment


    Review response a_er 2-3 months, or according to
    clinical urgency
    Adjust treatment (including non-pharmacological
    treatments)
    Consider stepping down when asthma has been well-
    controlled for 3 months

    Mild asthma

    Infrequent symptom
    No nocturnal symptoms
    PED 80-100 %

    Moderate asthma

    Frequent symptoms
    Nocturnal symptoms present
    PEF 60-80 %

    Severe chronic asthma

    Persistent symptoms
    Frequent nocturnal symptoms
    PEF less than 60 %

    Very severe asthma

    Persistent symptoms not controlled by step 3


    medica<ons

    Reviewing response and adjusting treatment


    n

    How often should asthma be reviewed?


    1-3 months after treatment started, then every 3-12 months
    During pregnancy, every 4-6 weeks
    After an exacerbation, within 1 week

    Stepping up asthma treatment


    Sustained step-up, for at least 2-3 months if asthma poorly
    controlled
    Short-term step-up, for 1-2 weeks, e.g. with viral infection or
    allergen
    Day-to-day adjustment

    Stepping down asthma treatment


    Consider step-down after good control maintained for 3 months
    Find each patients minimum effective dose, that controls both
    symptoms and exacerbations

    GINA 2015

    Global Initiative for Asthma

    Non-pharmacological interventions
    n

    Avoidance of tobacco smoke exposure

    Encourage physical activity

    Occupational asthma
    Ask patients with adult-onset asthma about work history. Remove
    sensitizers as soon as possible.

    Avoid medications that may worsen asthma


    Always ask about asthma before prescribing NSAIDs or betablockers

    GINA 2015, Box 3-9

    Global Initiative for Asthma

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