ASTHMA

BRONCHIAL ASTHMA
• Chronic inflammatory disorder associated with widespread airway
hypersensitiveness
• Causes variable airway obstruction which is reversible spontaneously
or with treatment
• Affects 300 million people worldwide including 12% of Philippine
population
• 10-12% adults; 15% children
• Gender predilection changes
Definition of Asthma
• A chronic inflammatory disorder of the airways
• Many cells and cellular elements play a role
• Chronic inflammation is associated with airway hyper
responsiveness that lead to recurrent episodes of
wheezing, breathlessness, chest tightness and
coughing
• Widespread, variable and often reversible airflow
limitation
Bronchial Asthma
• Symptoms: cough, breathlessness, chest tightness and wheezing
• Caused by genetic and environmental factors
• Disease cause physiological and pathological pulmonary changes in
affected individuals
Burden of Asthma
• Asthma is one of the most common chronic diseases worldwide with
an estimated 300 M affected individuals
• Prevalence increasing in many countries, esp in children
• A major cause of school/work absence
Risk Factors for Asthma
• Host factors: predispose individuals to, or protect them from
developing asthma
• Environmental factors: influence susceptibility to development of
asthma in predisposed individuals, precipitate asthma exacerbations,
and/or cause symptoms to persist
Asthma Inflammation: Cells and Mediators
Factors that Exacerbate Asthma
• Allergens
• Respiratory infections
• Exercise and hyperventilation
• Weather changes
• Sulfur dioxide
• Food, additives, drugs
Factors that Influence Asthma Development
and Expression
• Host Factors • Environmental Factors
➢Genetic ➢Indoor allergens
✓Atopy ➢Outdoor allergens
✓Airway hyper ➢Occupational sensitizers
responsiveness ➢Tobacco smoke
➢Gender ➢Air pollution
➢Obesity ➢Respiratory infections
➢Diet
Asthma Diagnosis
• History and patterns of symptoms
• Measurement of lung function
➢Spirometry
➢Peak expiratory flow
• Measurement of airway responsiveness
• Measurements of allergic status to identify risk factors
• Extra measures may be required to diagnose asthma in children 5 yrs
and younger and the elderly
Diagnosis
• Clinical diagnosis
➢Breathlessness
➢Cough
➢Wheezing
➢Chest tightness
• Diagnostic examinations
➢Spirometry
➢Peak flow measurements
➢Skin allergy tests
➢Airway hyperresponsiveness measurements
Is It Asthma?
• Recurrent episodes of wheezing
• Troublesome cough at night
• Cough or wheeze after exercise
• Cough, wheeze or chest tightness after exposure to airborne allergens
or pollutants
• Colds “go to the chest” or take more than 10 days to clear
Asthma Diagnosis
• History and patterns of symptoms
• Measurements of lung function
➢Spirometry
➢Peak expiratory flow
• Reversibility in spirometry: 12% and 200 mL from PreBD
• PEF: 60L/min or> 20% of PreBD
• Diurnal variation in PEF: > 20%
Asthma Diagnosis
Asthma Management and Prevention
Program: Five Components
1. Develop Pt/Doctor Partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat and monitor asthma
4. Manage Asthma exacerbations
5. Special considerations
Goals of Long-term Management
• Achieve and maintain control of symptoms
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal
levels as possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality
 Clinical Control of Asthma (Global Strategy
for Asthma Management and Prevention)
• Determine the initial level of control to implement treatment (assess
pt impairment)
• Maintain control once treatment has been implemented (assess pt
risk)
 4. Level of Control
Assessment of current clinical control (over 4 weeks)
Characteristics Controlled Partly controlled Uncontrolled
Daytime symptoms None (2x or More than 2x 3 or more of features
less/week) of partly controlled

Nocturnal symptoms/ None any Any exacerbation in

awakenings any week of asthma

Limitation of activities None Any

Need for reliever/ rescue None (2x or More than 2x

drug less/week)
Lung function (FEV1/PEF) Normal <80% predicted or
personal best
Assessment of future risk
(risk for exacerbation, instability, side effects, rapid decline in lung function)
1. Poor clinical control 2. frequent exacerbation in the past year 3. critical care admission due to
Assess Patient Risk
• Features that are associated with increased risk of adverse events in
the future include:
➢Poor clinical control
➢Frequent exacerbations in past year
➢Ever admission to critical care for asthma
➢Low FEV1, exposure to cigarette smoke, high dose meds
Treatment for control
• CONTROLLERS
Inhaled/ Systemic Corticosteroid
Inhaled/ Systemic Long-Acting Beta2 Agonist
Cromones (Nedocromil)
Leukotriene Modifiers (Montelukast, Zileuton)
Anti-IgE (Omalizumab)
Theophylline
Bronchial Thermoplasty (BT)
• RESCUE
Inhaled / Oral Rapid-Acting Beta2 Agonist
Inhaled Anticholinergic
Systemic Corticosteroid (Severe Exacerbations)
Theophylline
Factors Involved in Non-Adherence
Medication Usage Non-Medication Factors

• Difficulties associated with • Misunderstanding/ lack of

inhalers information
• Complicated regimens • Fears about side effects
• Fears about, or actual side • Inappropriate expectations
effects • Underestimation of severity
• Cost • Attitudes toward ill health
• Distance to pharmacies • Cultural factors
• Poor communication
Controller Medications
• Inhaled glucocorticosteroids
• Leukotriene modifiers
• Long-acting inhaled Beta2-Agonists in combination with inhaled
glucocorticosteroids
• Systemic glucocorticosteroids
• Theophylline
• Cromones
• Anti-IgE
Reliever Medications
• Rapid-Acting Inhaled Beta2-Agonist
• Systemic glucocorticoids
• Anticholinergics
• Theophylline
• Short-acting oral Beta2-agonists