Bronchial Asthma

Basheer Khassawneh, MD, FCCP

Associate Professor, Faculty of Medicine Pulmonary and Critical Care and Sleep Medicine CMO, King Abdullah University Hospital Jordan University of Science and Technology

Definition and Characteristics

A chronic inflammatory disorder of the airways Causing recurrent/intermittent episodes of:
Wheezing Breathlessness Chest tightness Cough particularly at night

Symptoms are worse at night and/or in the early morning

Definition and Characteristics

Variable airflow limitation that is at least partly reversible either spontaneously or with treatment Airway hyper-responsiveness to a variety of stimuli

The Scope of the Problem -USA

Affects 14 -15 million people 6% of children under 18 years of age Inner city children have highest rates Rates higher among females Rates higher among blacks

How Asthma Affects the General Population Experience With Asthma: Public Survey
Family Members With Asthma 35.1%

Past History of Asthma 5.8%

Currently Experiencing Asthma 6.7% None 23.0%

Friends/Coworkers With Asthma 29.4%

Base: All respondents (unweighted N=1000).

Risk Factors for Asthma

Allergy/Atopy Family history of asthma/allergy Perinatal exposure to tobacco smoke Early viral respiratory tract infections Low birth weight Environmental pollution Low socio-economic status Passive smoking

Atopy and Asthma

Atopy is associated with elevated total IgE Specific IgE against common aero-allergens Positive skin test to common aero-allergens Asthmatics are more atopic than nonasthmatics Atopy is more common in childhood asthma House dust mite is the most common aerallergen worldwide

Indoor Air Triggers

Environmental tobacco smoke Cockroaches House dust mites - common Animal dander - cats Mold

Outdoor Air Triggers

Particulate matter (air pollution)
Combustion products Industrial emissions Vehicle exhaust

Outdoor pollens
Olive

Additional Triggers
Viral upper respiratory infections Exercise and hyperventilation GERD Sinusitis and rhinitis Diet Cold air Drugs
Aspirin,

NSAID, beta blockers

Asthma Diagnosis
History

and patterns of symptoms

examination

Physical

Measurements
Measurements

of lung function
of allergic status to identify

risk factors

Symptoms and Signs

Variety of symptoms
wheeze shortness of breath chest tightness cough

Asthma symptoms tend to be:

Variable and intermittent Worse at night Provoked by triggers

Additional Elements in History

Personal or family history of
Asthma Atopic condition: eczema, allergic rhinitis

Worsening of symptoms after

Exposure to recognized triggers Taking aspirin, NSAID, b-blockers Exercise

Physical Signs of Asthma

During exacerbations
Wheeze, silent chest, hyper-resonant

Wheeze: are diffuse, polyphonic, bilateral and particularly expiratory Chronic asthma may have signs of hyperinflation with/without wheeze

Differential Diagnoses
COPD Gastro-esophageal reflux disease (GERD) Post nasal drip (allergic rhinitis, sinusitis) Cystic fibrosis Tumor: Laryngeal, tracheal, lung Bronchiectasis Foreign body Vocal cord dysfunction Hyperventilation

Diagnostic Tools
Peak flow monitoring by patients Pulmonary function testing (spirometry) Bronchoprovocative challenge

Pulmonary Function Test

Obstructive pattern
Forced Vital Capacity (FVC) Forced Expiratory Volume in 1 second (FEV1) FEV1/FVC < 70%

Reversible airflow limitation

FEV1 increases by 15% after inhalation of a rapid-acting beta-2-agonist

Clinical Control of Asthma

No (or minimal)* daytime symptoms

No limitations of activity
No nocturnal symptoms

No (or minimal) need for rescue medication

Normal lung function

No exacerbations
_________
* Minimal = twice or less per week

Levels of Asthma Control

Characteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Controlled
(All of the following)

Partly controlled
(Any present in any week)

Uncontrolled

None ( 2/ week) None None

> 2 / week Any Any 3 or more features of partly controlled asthma present in any week

Need for rescue / reliever treatment

Lung function (PEF or FEV1)

None ( 2 / week)
Normal

> 2 / week
< 80% predicted or personal best (if known) on any day

Exacerbation

None

1 / year

1 in any week

Asthma Management
Although there is no cure for asthma
Appropriate management most often results in the achievement of control

Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Anti-IgE Theophylline Systemic glucocorticosteroids Long-acting inhaled 2-agonists

Reliever Medications
Rapid-acting inhaled 2-agonists
Salbutamol

Systemic glucocorticosteroids Anticholinergics

Ipratropium

Theophylline Short-acting oral 2-agonists

Asthma Exacerbations
Episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness Characterized by decreases in expiratory airflow Potentially life-threatening and treatment requires close supervision

Manage Asthma Exacerbations

Primary therapies for exacerbations
Repetitive administration of rapid-acting inhaled 2-agonist Systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

Acute Asthma
Emergency Department Management
Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if needed Good Response Observe for at least 1 hour Incomplete/Poor Response Add Systemic Glucocorticosteroids Good Response If Stable, Discharge to Home Poor Response Respiratory Failure

Discharge

Admit to Hospital

Admit to ICU

ORAL HEALTH CHANGES IN PATIENTS WITH ASTHMA

Increased rate of caries development Reduced salivary flow Oral mucosal changes Gingivitis Orofacial abnormalities
Increased upper anterior and total anterior facial height Higher palatal vaults Greater overjets Higher prevalence of posterior crossbites

Thank You