Bronchial Asthma

Liza Peikrishvili
2022
Definition of asthma

GINA 2021
Asthma - diagnosis

GINA 2021
 Terminology
• Phenotype: The observable characteristics of a disease, such as
morphology, development, biochemical or physiological properties, or
behaviour.
– Examples: allergic asthma, aspirin-exacerbated respiratory disease, severe
eosinophilic asthma

• Endotype: A subtype of disease, defined functionally and pathologically by

a distinct molecular mechanism or by distinct treatment responses
– Examples: emphysema due to alpha1-antitrypsin deficiency

• Biomarker: A defined characteristic measured as an indicator of normal

biologic processes, pathogenic processes or response to an intervention
– Potential examples: FeNO, blood eosinophils – but these may not meet quality
criteria for biomarkers

Anderson, Lancet 2008; Reddel, ERJ Open Res 2019 © Global Initiative for Asthma, www.ginasthma.org
 Asthma – phenotypes:
Allergic asthma

 Often starts in childhood, associated with past and/or family history

of allergic diseases-eczema, allergic rhinitis, food and drug allergy

 Sputum reviles eosinophilic inflammation

 Good response to ICS (inhalation corticosteroid)

Asthma – phenotypes:
Non-allergic asthma

 Not associated with allergy

 Sputum contains neutrophilic, eosinophilic cells
 Less short term response to ICS
 Asthma – phenotypes:
Adult-onset-late asthma

 Patients are mainly women, with first manifestation in adult life

 Patients are non-allergic, require higher doses of ICS or
the are refractory to corticosteroids
 Occupational asthma should be ruled out
 Asthma – phenotypes:
With persistent airflow limitation

Airflow limitation is persistent or incompletely reversible

This is thought to be due to airway wall remodeling
 Asthma – phenotypes:
Asthma with obesity

 Some obese patients with asthma have

 prominent respiratory symptoms and little
eosinophilic airway inflammation
Main information, analysis and
investigations for diagnosis of
asthma
1. Anamnesis
2. Family history
3. Occupational history
4. Home environment
5. Examination
6. Pulmonary function testing-spirometry
7. IgE
8. Sputum eosinophils
9. Exhaled nitric oxide
10. Dlco - Diffusing capacity for the lungs measured
using carbonmonoxide, also known as transfer factor
(0,3% CO+ 21% O2+0.3% methane /N2))
Physiologic Features
Pathologic breath sounds:
Wheezing (expiratory)

https://www.youtube.com/watch?v=T4qNgi4Vrvo
Pathologic breath sounds:
Stridor (inspiratory)

https://www.youtube.com/watch?v=JSdEK79J4dw
Pathologic breath sounds:
Crackles

https://www.youtube.com/watch?v=LHqqvrm2j6g
Asthma symptoms
Asthma comorbidities

 Rhinitis
 Rhinosinusitis
 GERD
 Obesity
 OSA
 Depression and
anxiety
Common Triggers

Nelson, textbook of pediatrics,

p. 783 table 138-3
Asthma classification
 Main information, analysis and
investigations for diagnosis of asthma

1. Anamnesis
2. Family history
3. Occupational history
4. Home environment
5. Examination
6. Pulmonary function testing-spirometry
7. IgE
8. Sputum eosinophils
9. Exhaled nitric oxide
10. Dlco - Diffusing capacity for the lungs measured using
carbonmonoxide, also known as transfer factor (0,3% CO+
21% O2+0.3% methane /N2))
GINA 2021
 Spirometry test

https://www.youtube.com/watch?v=lWHx31BquBA
Measurement of fractional exhaled
nitric oxide (FENO)

https://www.youtube.com/watch?v=elwDgxBcFI0

The FeNO test, which stands for the fractional concentration of exhaled nitric oxide, is
performed using a portable device that measures the level of nitric oxide in parts per
billion (PPB) in the air you slowly exhale out of your lungs.
Dlco - Diffusing capacity for the lungs
measured using carbon monoxide

https://www.youtube.com/watch?v=fQOk84DHAis
Dlco – normal ranges
Differential Diagnosis
 DD – Asthma and COPD
Asthma COPD
Starts mainly in childhood Stars after 40 y/o
Often co-exists other atopic diseases: atopic No other allergic diseases
dermatitis, rhinitis etc.
Often exists in close relatives Rare exists in relatives

Smoking has less important role Smoking-takes very important part

Complains are variable during the day Complains are stable, gets more and more step by
step
Eosinophil type inflammation Neutrophil type of inflammation
Strongly positive response after steroids Low response after steroids

IgE elevation is common IgE elevation less common

Obstruction with reversibility by spirometry Obstruction without reversibility by spirometry

After treatment spirometry reaches normal values After treatment spirometry never reaches normal
values, even after clinical recovery

Eosinophils in blood elevated (not obligatory) No eosinophils in blood

FENO elevated FENO not elevated

Dlco- Norma or slightly increased Dlco- often decreased

Differential diagnosis – Asthma and
COPD
 Goals of asthma treatment
• Few asthma symptoms
• No sleep disturbance Symptom control
• No exercise limitation
• Maintain normal lung function
• Prevent flare-ups (exacerbations)
Risk reduction
• Prevent asthma deaths
• Avoid medication side-effects

• The patient’s goals may be different from these

• Symptoms and risk may be discordant – need to assess both
© Global Initiative for Asthma, www.ginasthma.org
 Terminology
• Uncontrolled asthma
– Frequent symptoms and/or flare-ups (exacerbations)
– Many of these patients may potentially have mild asthma, i.e. their asthma could be
well-controlled with low dose ICS, if taken regularly

• Difficult-to-treat asthma
– (not difficult patients!)
– Asthma uncontrolled despite prescribing high dose preventer treatment
– Contributory factors may include incorrect diagnosis, incorrect inhaler technique, poor adherence,
comorbidities

• Severe asthma
– “Severe asthma” has had many different meanings (Taylor, ERJ 2008; Reddel AJRCCM 2009)
– Now defined as asthma that is uncontrolled despite maximal optimised therapy and treatment of
contributory factors, or that worsens when high dose treatment is decreased (Chung, ERJ 2014)
i.e. relatively refractory to corticosteroids (rarely completely refractory)
© Global Initiative for Asthma, www.ginasthma.org
How common is severe
asthma?
Mandatory literature:
1. Clinical Allergy: Diagnosis and Management Gerald W.
Volcheck; USA -2009 pp. 189-271
2. GINA 2019
3. Oxford Handbook of Clinical Immunology and Allergy
3rd edition, 2013, G. Spickettpp.134-137
4. Allergy and Clinical immunology Hugh A. Sampson,
Scott L. Friedman-2015 pp.77-114