Asthma

Izzatullah Khan

Assistant Professor
Pharm.D (BMU) MSc. (UK)

Contents

Introduction to Respiratory system

Introduction to asthma
Epidemiology
Etiology
Risk factors
Pathophysiology
Clinical manifestations
Investigations
Management

INTRODUCTION TO RESPIRATORY
SYSTEM

Asthma means
laboured breathing ----In Greek
---The national UK guidelines define Asthma as :

____A chronic inflammatory disorder of the

airways which occur in susceptible individuals;
inflammatory symptoms are usually associated
with widespread but variable airflow obstruction
and an increase in airway response to a variety of
stimuli. Obstruction is often reversible either
spontaneously or with treatment._____

EPIDEMIOLOGY
Over 5 million people in the UK ,have asthma &
around 300 million world wide.
In the UK, there are approximately 1400 deaths
from asthma each year.
Probability of children having asthma symptoms
is between 5 to 12 % with high occurrence in boys
than girls.

 Epidemiologic studies strongly support the

concept of genetic predisposition to the
development of asthma .
Genetic factors account for 35 to 70% of the
susceptibility.

ETIOLOGY
The two main causes of
asthma symptoms are:

Airway
hyperresponsiveness

Increased tendency
of the airway to react
to stimuli or triggers
to cause an asthma
attack.

Bronchoconstriction

A narrowing of
airways that
causes airflow
obstructions.

Trigger

Examples

Allergens

Pollens
Moulds
Animals (dander, saliva ,urine)

Industrial chemicals

Isocyanate containing paints

Epoxy resins
Hair sprays

Drugs

Aspirin
Ibuprofen
Prostaglandin synthetase inhibitor

Foods

Dairy products
Nuts
Sea foods

Environmental
pollutants

Traffic fumes
Cigarette smoke

Other industrial
triggers

Wood or grain dust

Cotton

Miscellaneous

Cold air
Viral respiratory tract infections
Emotions or stress

Pathophysiology

There are 2 major elements in the pathophysiology:

inflammation and airway hyper-responsiveness (AHR).
Airway inflammation occurs secondary to a complex
interaction of inflammatory cells, mediators, and other
cells and tissues in the airway.
An initial trigger leads to the release of inflammatory
mediators, which leads to the consequent activation and
migration of other inflammatory cells. The inflammatory
reaction is a T-helper type 2 (Th2) lymphocytic response.
Th2 inflammation is characterised by the presence of
CD4+ lymphocytes that secrete interleukin (IL)-4, IL-5,
and IL-13, the chemokine eotaxin.

Other WBCs involved are eosinophils,

basophils and mast cells, macrophages, and
invariant NK T cells, and in near-fatal or
status asthmaticus, neutrophils are
important.
These cells move to the airway, causing
changes in the epithelium, airway tone, and
related autonomic neural control and hypersecretion of mucus, mucociliary function
alteration and increased smooth muscle
responsiveness.

Antigen
(allergen)

IgE antibody
antigen
reaction

Neutrophil

Eosinophil

Platelet activating factor

(PAF)

Bronchial
hyperactivity

Mucosal
edema

CELL DERIVED MEDIATORS

(Histamine, Prostaglandin, Leukotrienes, Cytokines, PAF)

Hypertrophy &
Hyperplasia of bronchial
smooth muscles

Mucus gland hypertrophy

Increased mucus
production
Airway plugging
Airway edema
Acute bronchoconstriction

CLINICAL
MANIFESTATIONS
Persistent cough
Dyspnoea(difficulty in breathing)
Wheezing(a high-pitched noise due to turbulent airflow through a
narrow airway)
Breathlessness
Hyper expansion of the thoracic cavity & lowering of the
diaphragm.
Difficulty is felt both during inspiration and expiration.
Severe contraction of abdominal muscles.

In asthma

Residual volume
Functional residual capacity
(FRC)

increased

Tidal volume (TV)

Forced expiratory volume (FEV 1)
Vital capacity
Partial pressure of oxygen in
blood
Alveolar ventilation

Decreased

Investigations
1.. Forced expiratory volume (FEV1):
Measure of the FEV in the first second of exhalation.
2.. Forced vital capacity (FVC):
Assessment of the maximum volume of air exhaled with maximum effort after maximum inspiration.
Percentage of total volume of air
exhaled=FEV1/FVC
Normal individual can exhale 70% or their capacity in 1 sec.
In Asthma

In asthma

FVC

FEV1
Decreases

FEV1:FVC

Remains
normal /slightly
decreases

decreases (usually <0.7)

3..Peak expiratory flow rate (PEFR):

Maximum flow rate that can be forced during expiration.
Used to asses the improvement/deterioration in the
disease and effectiveness of treatment.

Diagnosis:
Diagnosing asthma generally includes:
Medical history
Physical examination
Pulmonary function test
Furthermore it can be confirmed by measuring the
response to a bronchodilator by examining a
patients day to day variation in PEF readings.
A diurnal variability of 60L/min (or more than
20%) is highly suggestive in asthma.

Management
A: Non pharmacological management
B: pharmacological management

Non pharmacological
management
Supervised swimming : helps to avoid exercise
induced attacks
Avoid skipping
Avoid all trigger factors

Pharmacological
Treatment
Reliever medication
Preventive medication

1..Reliever medication
Classes

Drugs

Route of
administration

Short acting beta

Salbutamol
adrenergic agonists Terbutaline

Inhaled
Nebulised

Long acting beta

Salmeterol
adrenergic agonists Formeterol
(LABA)

Inhaled

Combination
therapy

ICS/LABA
Inhaled
(budesonide/formeterol)

2..Preventive medications
Classes

Drugs

Anti-inflammatory agents

1..Inhaled corticosterods:
Beclometasone diproprionate
or budesonide
2..Cromones:
Sodium cromoglicate
Nedocromil sodium

Leukotriene receptor
antagonists

Zafirlukast
Montelukast

Anti IgE monoclonal

antibodies

Omalizumab

Oral corticosteroids

Glucocorticoids
mineralocorticoids

Steroid sparing agents

Methotrexate
Ciclosporin

References
Clinical pharmacy and therapeutics edited by Roger Walker and cate
whittlesea,5th edition, page no. 412-430
Clinical pharmacy written by Irfan Bashir, revised edition, page no.
258-262
Basic pathology written by Robbins,8th edition, page no. 489-492
Essentials of medical physiology written by K Sembulingam and Prema
Sembulingam,5th edition, page no. 703
Asthma in Adult, http://bestpractice.bmj.com/bestpractice/monograph/44/basics/pathophysiology.html