Definition

It is a syndrome characterized by AIRFLOW

OBSTRUCTION that varies markedly,
both spontaneously and with treatment.
Narrowing of the airways is usually
reversible, but in some patients with chronic
asthma there may be an element of
irreversible airflow obstruction

 pathologically by bronchial inflammation with

prominent eosinophil infiltration
physiologically by bronchial hype-reactivity, and
clinically by variable cough, chest tightness and
wheeze

Epidemiology
It affects approximately 10-15% of children
and 5-10% of adults
Prevalence is greater in industrialized
countries
Prevalence is increasing world-wide

Pathology of asthma
Infiltration with inflammatory cells (esp.
eosinophils and T-lymphocytes)
Patchy epithelial shedding
Airway smooth muscle thickening
Subepithelial fibrosis
Mucus gland and goblet cell hyperplasia
widespread mucus plugging in fatal asthma

Mechanisms of asthma
Inflammation underlies airway
hyperresponsiveness
The inflammation is of characteristic pattern and it
involves interaction between many inflammatory
cells
This results in the release of multiple
inflammatory mediators
Inflammatory mediators result in
bronchoconstriction, mucus secrition, exudation of
plasma and airway hyperresponsiveness

 Neural mechanism may amplify the

asthmatic inflammation
Structural changes may occur with
subepithelial fibrosis, airway smooth
muscle hyperplasia and new vessel
formation. These changes may underlie
irreversible airflow obstruction

Types of asthma

Allergic (extrinsic) asthma

Non-allergic (intrinsic) asthma
Occupational asthma
Aspirin induced asthma
Asthma of infancy(<2 yr of age)

Allergic asthma

Onset usually in childhood

May persist into adulthood
Remission in adolescence is common
Associated with allergic rhinitis and atopic
dermatitis in variable combination

Intrinsic asthma
Onset in adults
No external inciter is recognized
Often associated with perennial non-allergic
rhinitis
Accounts for approx. 10% of adult asthma

Occupational asthma
Due to exposure to chemical sensitizers at
work
Unrelated to atopic status
Some occur in atopics due to allergen
exposure at work

Aspirin induced asthma

Special type of intrinsic asthma
It is a metabolic, pharmacological disorder
acute asthma attacks on first and subsequent
exposure to aspirin and NSAID

Asthma of infancy
Recurrent bouts of significant airflow
limitation in small airways from viral
infections
Often remits as child gets older
not associated with atopy
Sometimes called wheezy bronchitis

Clinical features
Symptoms
Triggers
Physical signs

Symptoms
Wheeze-- intermittent, worse on expiration,
chracteristically relieved by an inhaled 2agonist
Cough-- usually unproductive
Chest tightness
SOB
Prodromal symptoms may precede an attack

Triggers

Allergens (house dust mite, pollen, animal dander, moulds)

Irritants (tobacco smoke, air pollutants, strong odours, fumes)
Physical factors (exercise, cold air, hyperventillation, laughter,
crying)
Upper respiratory tract viral infections
Emotions
Occupational agents (chemical sensitizers, allergens)
Drugs (beta blockers,NSAID)
Food additives (metabisulphite,tartrazine)
Change in weather
Endocrine factors (menstrual cycle, pregnancy,thyroid disease)

Physical signs

Expiratory ronchi- widespread

Hyperinflation of chest
Use of accessory muscles
Associated signs: nasal polyps, flexure
eczema

DD in adults

Mechanical obstruction of airways

COPD
Heart failure
PE
Vasculitides
Carcinoid syndrome with hepatic
secondaries

Principles of treatment
Educate patients to develop a partnership in
asthma management
Assess and monitor severity with objective
measurement of lung function
Avoid or control asthma triggers
Establish medication plans for chronic
management
Establish plans for managing exacerbations
Provide regular follow-up care

Clinical evaluation of severity

Number of daytime attacks lasting more than 24 hrs and needing extra
medication
The presence of completely symptom-free intervals lasting more than 4
weeks without medication
The frequency of waking at night due to asthma symptoms
The amount of absence from work or school because of asthma
The ability of the patients to keep up with peers in normal physical
activity
The number and type of medications required on regular basis
The frequency of using extra relief medications on an as needed basis
The frequency of hospital admission
The of life-threatening episodes

MEDICATIONS

Steroids
Beta-agonists
Cromolyn
Methylxanthines
Leukotriene modifiers
Anticholinergics

CORTICOSTEROIDS
Proven most effective benefit for chronic
control
Inhaled form preferred
Inhibit inflammatory cell migration and
activation
Decrease airway responsiveness
Reverse beta-receptor down regulation
Improve spirometry

CORTICOSTEROIDS
Side effects include thrush, cough,
dysphonia
Dexamethasone not included
Risks for children and growth suppression
not an issue
Used for any classification
Systemic steroids reserved for severe

CROMYLYN/NEDOCROMIL
Anti-inflammatory effect from blockage of
chloride channels for mast cells
Help inhibit allergy response and exercise
response
Proven to improve improve peak flow and reduce
beta-agonist use
Dosage usually 4 times per day
Safety well known
Less predictable response than corticosteroids

LONG ACTING BETA

AGONISTS
Not to be used for acute exacerbations
Directly stimulates beta receptors to relax
bronchial smooth muscle
Especially useful for nocturnal symptoms
Studies show that tolerance does not
develop
Can cause tachycardia, hypokalemia,
prolonged QT interval

METHYLXANTHINES
? Mechanism but does provide mild
bronchodilation
Not the preferred chronic therapy
Numerous adverse effects, risk of toxicity,
drug interactions, and lab monitoring

LEUKOTRIENE MODIFIERS
Use in children not widely approved
Few side effects-reported liver effects
Drug interactions with theophylline, warfarin,
terfenadine
Oral formulations once daily
Work to decrease leukotrienes and decrease
inflammation
Studies mostly on mild asthma-improves sx and
increase peak flow

QUICK RELIEF DRUGS

Short acting beta-agonist work within 30
minutes
All asthma patients should have this
available
Anticholinergics can give relaxation of
bronchial smooth muscle-no role in long
term management

STEPWISE APPROACH
Severe Persistent

High dose corticosteroid

Long acting bronchodil.
Oral steroids

Moderate Persistent

Anti-inflammatory
Long acting bronchodil.

Mild Persistent

Anti-inflammatory or
Leukotriene mod

Mid Intermittent

No daily medications

Asthma is a chronic inflammatory disorder of the

airway which manifest by symptoms such as episodic
breathlessness, wheezing, chest tightness and cough
particularly at night and the early morning.
Inflammation makes the airways sensitive to stimuli
such as allergens, chemical irritation, tobacco smoke
cold air or exercise.
Bronchial asthma is one of the most common chronic
disease, is of all asthmatic patients suffer from chro
nic symptoms recuiri continuous administration of
anti asthmatic drugs.

Chronic asthma is the asthma for which we should give

continuous and cautions treatments in drily clinical practice.
Chronic asthma is characterized by :
1. Clinically : recurrent episodes of dyspnea and wheezing
caused by reversible airway narrowing.
2. Physiologically : increased airway responsiveness.
3. Pathologically : by inflammation of the airway Eo
infiltration and damage to the airway epithelioma.
4. Immunologically : increased Ig eproduction.

Ask patients :
Dose the patients have ;
Reccurent attacks of wheezing
Cough or wheeze at night?
Cough or wheeze after exercise
Cough, wheeze of chest tightness of exposure to
allergens or pollutants
Classive severity of asthma :
Step I : INTERMITTEN
Step II: MILD PERSISTENT
Step III : MODERATE PERSISTENT
Step IV : SEVERE PERSISTENT

SABA
1. QUICK RELIEF

ANTI CHOLENERCKS
SHORTACTING THEOPHYLLIN
ADRENALIN INJECTION

2. LONGTERM PREVENTIVE
- Corticosteroid
- Soding cromoglycate
- Nedocromil
- LABA
- Sustained released theophylline
- Ketotifen

Monitoring the course of asthma :

- Review of symptoms
- Measurement of lung function as much as
possible
Long-term peak flow monitoring for patients
with persistent asthma is important for
providing objective measurement of the
course of the disease.

THE BEST way to stop asthma attacks is presentation.

Identify and avoid triggers eg :
- Domestic dust mites
- Animal allergens
- Tobacco smoke
- Cackroach
- Rold
- Smoke
- Cold
- Physical activity