BRONCHIAL ASTHMA

Chronic inflammatory disorder of airways, characterized by reversible airflow obstruction Clinical features of Bronchial Asthma Episodic asthma - No respiratory symptoms and signs between episodes of asthma - Can be triggered by allergens, exercise or viral infection or may be spontaneous - May last for hours, days or even weeks Chronic asthma - Bronchospasm during night and early morning may be chronic unless controlled by appropriate therapy - Episodes of severe acute asthma can occur - Recurrent episodes of frank respiratory tract infection may make difficulty to distinguish from chronic bronchitis Precipitating factors - Exposure to known allergen or irritant [Pollens, Animals, Dusts, Smoke] - Respiratory tract infection - Drugs [omission of treatment or use of drugs aggravating bronchospasm] - Emotional stress - Cold air or exercise-induced asthma Investigations Spirometry

Lung volumes and capacities INSPIRATORY RESERVE VOLUME TIDAL VOLUME EXPIRATORY RESERVE VOLUME RESIDUAL VOLUME VITAL CAPACITY TOTAL LUNG VOLUME FUNTIONAL RESIDUAL CAPACITY

RESIDUAL VOLUME

FEV1 : VC (or) PEF o Serial PEF morning dipping to distinguish from those with fixed or irreversible airflow obstruction associated with COPD to monitor the response to treatment of severe acute asthma to monitor patients with poorly controlled disease

Bronchial provocation tests Exercise test

Histamine or methacholine test Occupational exposure test

o Trial of oral steroids e.g. prednisolone 30 mg daily for 2 weeks Sputum eosinophil count increased Peripheral blood eosinophil count increased Increased serum level of total or allergen-specific IgE (radioallergosorbent test) CXR o hyperinflation o collapse, pneumothorax, mediastinal and subcutaneous emphysema o infection o allergic bronchopulmonary aspergillosis

Arterial blood gas analysis

Features of severity
-

Respiratory rate > 25/min Pulse rate > 110/min Pulsus paradoxus Systolic BP < 100mmHg Unable to complete sentences in one breath or too breathless to talk or feed PEF < 50% of expected

Life-threatening features
Cannot speak Central cyanosis Exhaustion, confusion, reduced conscious level Bradycardia Silent chest Unrecordable PEF PaO2< 8kPa (60 mmHg ) despite FiO2 of 60% Rising PaCO2 or PaCO2 > 6kPa (45mmHg) Failure to improve despite maximal therapy

Management of chronic asthma

Avoidance Hyposensitization Patient education and PEF monitoring

OCCASIONAL USE OF INHALED SHORT-ACTING 2 ADENORECEPTOR AGONIST LOW-DOSE INHALED STEROIDS (OR OTHER ANTI-INFLAMMATORY AGENTS)

Treatment steps

HIGH-DOSE INHALED STEROIDS OR LOW-DOSE INHALED STEROIDS + LONGACTING INHALED 2 ADENORECEPTOR AGONIST

Management of acute severe asthma

* INITIAL TREATMENT o Sit the patient up in bed

HIGH-DOSE INHALED STEROIDS AND REGULAR BRONCHODILATORS ADDITION OF REGULAR ORAL STEROID THERAPY

o 60% O2 o Nebulized 2 agonist (salbutamol 2.5 5 mg or terbutaline 5 10 mg)

via O2 [can be repeated up to every 30min] +/- ipratropium bromide 0.5 mg o Steroid i.v. hydrocortisone 200 mg 6-hourly oral prednisolone 30 60 mg daily o Adequate hydration o Correct or treat the precipitants * MONITORING PROGRESS * IF THE PATIENT'S CONDITION IS DETERIORATING - Salbutamol 250 g i.v. over 10 min - Aminophyline infusion 500 g/kg/hour - Subcutaneous Adrenaline 0.5mg - Indications of CPAP / Mechanical ventilation coma respiratory arrest exhaustion, drowsiness, confusion deterioration of ABG despite optimal therapy PaO2 < 8kPa and falling PaCO2 > 6kPa and rising pH <7.3 and falling * ON-GOING THERAPY * DISCHARGE