by

CAUNTONGAN, NORHATA P.
Medicine Clerk
Definition
• Chronic inflammatory disease of airways
characterized by increased responsiveness of the
tracheobronchial tree to multiple stimuli.

• Manifest physiologically by a widespread

narrowing of air passages, which may be
relived spontaneously or as a result of
therapy; and clinically by paroxysms of
dyspnea, cough, and wheezing.
Epidemiology
Prevalence increase by 4 % each year

In general population prevalence is higher among

females; in children it is higher among males.

In Philippines prevalence of 12% in children age

13-14 yrs. And 17-22 % in older age groups.

Highest prevalence was found in UK, Australia,

and New Zealand.
Etiology
House dust mites
Cockroaches
Animal allergens (cats, dogs)
Indoor & outdoor respiratory irritants
 Air pollution
 Tobacco smoke
Respirator y infections (may also exacerbate
asthma)
PATHOGENESIS
 Entry of allergens in the airway thru inhalation triggers
inflammatory activity.
 Release of inflammatory mediators from eosinophils and mast cells
result in persistent bronchial inflammation.
 Airways undergo structural abnormalities resulting in:
 Fibrosis
 Increase in mass of smooth muscle and mucus glands
 Epithelial shedding
 Thickening of reticular basement membrane
 Fibronectin deposition in the subepithelial layer
 These result in AIRWAY REMODELING as physiologic consequence
of:
 Increase in airway hyperresponsiveness
 Non-reversibility of airway obstruction and residual obstruction
after bronchodilator & anti-inflammatory therapy
CLINICAL
MANIFESTATIONS
 Triad (typically):  If prolonged:
1. dyspnea  loss of adventitial sounds
 High-pitched wheezing
2. cough
3. wheezing
TRIAD of:use of accessory muscles
 Active
 At onset:  Dev’t of paradoxical pulse
sense of constriction (on  End of attack:
chest), often w/ non-
productive cough
dyspnea frequently marked by a cough
w/thick, stringy mucus

audible respiration,
cough Less typical s/sx of asthma:
1. intermittent episodes of non-
prominent wheezing,
wheezing
prolonged expiration; often
productive cough; or
2. exertional dyspnea
w/ tachypnea, tachycardia,  Normal breath sounds
mild systolic HPN
 May wheeze after forced exhalation
 May show ventilatory impairments
rapidly overinflated lungs, when tested
inc. anteroposterior diameter
DIAGNOSIS 
Correlation of:
Clinical History (increasing accuracy w/ >1 sx)
 Cough that worsens at night
 Wheeze

 Difficulty breathing

 Chest tightness

Clinical Findings
 Presence of wheeze at normal breathing or its
appearance after prolonged forced expiratory time of
≥6 secs.
Objective Measurements of airflow obstruction
and/or bronchial responsiveness
 FEV1, PEFR, bronchoprovocation w/ methacholine or
 Asthma diagnosis confirmed by objective measures of
variable airway obstruction

OBJECTIVE INDICATOR OF SIGNIFICANT AIRFLOW

MEASURE
Spirometry LIMITATION
≥ 12% (minimum 200ml in adults)
improvement in FEV1 from the baseline
after use of inhaled bronchodilator.
≥ 20% (minimum 250 ml in adults)
improvement over time when sx are
stable or after 10-14 days of corticosteroid
Serial measures therapy.
≥ 20% change after using a
of PEFR bronchodilator over time.
Pre- & Post- ≥ 15% change after using inhaled
bronchodilator bronchodilator in the clinic in the absence
PEFR
Methacholine of spirometry.
Provocative concentration of
challenge methacholine resulting in a 20% fall in
(bronchoprovocat FEV1 from the baseline (PC20) < 8mg/ml.
ion)
Classification of
Asthma
May be according to:
•Etiology (allergenic, pharmacologic, environmental, occupational,
infectious, exertional, emotional)
•Severity
• Acute
 Hx of life-threatening acute attacks
 Hospitalization w/in previous year,
 Psychosocial problems
 Hx of intubation for asthma
 Recent reduction or cessation of glucocorticosteroi therapy
 Noncompliance with recommended medical therapy
• Chronic
• Based on Global Initiative on Asthma Classification of
Severity.
GINA Classification of Asthma Severity by Clinical Features
 Severity of Asthma Exacerbation in Adults

MILD MODERAT SEVERE RESP.

E ARREST
Breathless Walking, Talking, At rest, ---IMMINENT
can lie prefers hunched
down sitting forward
Talks in... Sentences Phrases Words ---
Alertness May be Usually Usually Drowsy/
agitated agitated agitated confused
RR Inc. Inc. Often
Accessory Usually Usually >30/min.
Usually Paradoxical
muscles not breathing
used
Wheeze Mod. Loud Usually loud Absent
often end-
expiratory
Pulse/minute <100 100-120 >120 Bradycardia
Severity of Asthma Exacerbation in Adults (cont.)

MILD MODERATE SEVERE RESP.

ARREST
IMMINENT
Pulsus Absent May be Often Absence
paradoxus <10 mmhg present present suggests
10-25 >25 mmhg respiratory
mmhg muscle
PEF after >80% 60-80% <60% fatigue
---
initial
bronchodilat
or (% med.
or
PaO2best)
(room Normal, >60 mmhg <60 mmhg ---
air) test not Cyanosis
Pa CO2 necessary
<45 mmhg <45 mmhg >45 mmhg
possible
resp. failure
SaO2 (room >95% 91-95% <91%
air)
 Classification of Severity of Asthma

Clinical Feature Before Medications

Treatment Required to
STEP 1. •Intermittent sxs < 1x/wk Maintain Control
•Intermittent reliever
Mild •Brief exacerbations (a few medications prn:
Intermittent hours to a few days) inhaled SABA
•Nocturnal sxs <2x/month
•Asymptomatic& normal lung
fxn bet. attacks
•PEF or FEV % >80%
predicted, variability <20%
STEP 2. •Sxs ≥1x/wk but <1x/day •Once daily
Mild Persistent •Exacerbations may affect controller meds
activity & sleep (usually inhaled
•Nocturnal sxs ≥2x/month antiinflammatory) +
•PEF or FEV % >80% possibly a LA
predicted, variability 20-30% bronchodilators
(esp. for nocturnal
sxs)
Classification of Severity of Asthma cont.

Clinical Feature Medications

Before Treatment Required to
STEP 3. •Sxs daily Maintain Control
•Daily controller meds
Moderate Persistent •Exacerbations affect of inhaled steroids &
activity & sleep a LA bronchodilators
•Nocturnal sxs (esp. for nocturnal
≥1x/month sxs)
•PEF or FEV % 60-80%
predicted, variability
STEP 4. >30%
•Continuous sxs •Multiple daily
Severe Persistent •Frequent controller meds:
exacerbations higher dose inhaled
•Frequent nocturnal steroids, LA
sxs bronchodilators, &
•PEF or FEV % <60% oral steroids (1
predicted,
NOTE: Presence of 1 feature variability
of asthma severity mg/kg/day)
is sufficient to place
patient in that catgory. >30%
TREATMENT
Differs according to severity.
First line of therapy for acute exacerbations is
β-2 agonists due to their rapid onset of action.
Algorithm for Asthma
Management
Based on Severity
Classification of Asthma in Acute Exacerbation

Using Spirometry
results in As Severe
Classification of Chronic Severity
Persistent
Asthma

Using Symptom As Mild to

Frequency in As Moderate
Intermittent
Classification of Chronic Severity Persistent
Asthma Asthma
Quick-Relief (Reliever)
Meds
Class Drug Dosage
Adrenergic Stimulants Catecholamines (thru
inhalation/parenteral
route)
epinephrine
isoproterenol
isoetharine
terbutaline
Resorcinols
fenoterol
Saligenins
albuterol
Methylxanthines Theophylline Starting dose 10
mg/kg/day up to 300
mg max.
Anticholinergics Ipratropium bromide
Long-term Controller
Meds
Class Drug Dosage
Glucocorticoids •Methylprednisolone •7.5-600 mg daily
singl dose (a.m.) or
qod as needed for
•Prednisolone control
•40-60 mg/d single or
2 divided doses for 3-
Long-acting B2- •Salmeterol 10 days 12 h for MDI
•2 puffs
agonists 21 µg/puff; 1 blister q
12 h for DPI 50 µ
g/blister
•1 cap q 12 h for DPI
Combined Meds Fluticasone/Salmetero 12 µg/single-use
1 inhalation bid ; dose
l capsule
depends on severity
of asthma
Leukotriene modifiers Montelukast 10 mg q hs
Thank you
Management of Acute Exacerbations of
Asthma
Management of Acute Exacerbations of Asthma cont.