Dr. Ali Sattar Lec.

2 / Asthma

Pulmonology
Asthma

1. Characteristically de ned by the following TRIAD :

a. Airway in ammation
b. Airway hyperresponsiveness
c. Reversible air ow obstruction

2. Asthma can begin at any age

3. Extrinsic versus intrinsic asthma :

a. Extrinsic asthma (most cases) ; Patients are atopic, that is, produce
immunoglobulin E (IgE) to environmental antigens. May be associated with eczema
and hay fever. Patients become asthmatic at a young age.
b. Intrinsic asthma ; Not related to atopy or environmental triggers
c. Triggers include pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral
infections, tobacco smoke, medications (B-blockers, aspirin), and exercise.
fi
fl
fl
 Note : increasing severity and
chronicity of the disease, remodelling
of the airway may occur, leading to
brosis of the airway wall, xed
narrowing of the airway & a reduced
response to bronchodilators
medication.

Types of Asthma:
1. Allergic (Atopic , Extrinsic) asthma.
2. Non Allergic(Non Atopic, Intrinsic)
asthma.
3. Cough-variant asthma: in this type of
asthma, Cough may be the dominant
symptom in some patients, and the lack of wheeze or breathlessness may lead to a
delay in reaching the diagnosis.
4. NSAID-induced asthma: patient is female and presents in middle age with asthma,
rhinosinusitis and nasal polyps.
5. Exercise induced asthma.
6. Cold induced asthma.
7. Occupational asthma.
8. Nocturnal asthma.

Clinical Features
1. Characterized by intermittent symptoms that include SOB, wheezing, chest
tightness, and cough. Symptoms have variable severity and may not be present
simultaneously. Usually occur within 30 minutes of exposure to triggers.
2. Symptoms are typically worse at night. Asthma characteristically displays a
diurnal pattern, with symptoms and lung function being worse in the early morning.
3. Wheezing (commonly during expiration, but can occur during inspiration)
the most common nding on physical examination. An inspection for nasal polyps
and eczema should be performed.

▪ Asthma is commonly mistaken for a cold or a persistent chest infectich (e.g.

longer than 10 days). Classical precipitants include exercise, particularly in coid
weather, exposure to airborne allergens or pollutants, and viral upper
respiratory tract infections. Rarely, a vasculitic rash may suggest eosinophilic
granulomatosis with polyangiitis (EGPA, formerly known as “Churg-Strauss”
syndrome).

"All That Wheezes Is Not Asthma"

fi
The most common cause of wheezing is asthma. However, any condition that
mimics large airway bronchospasm can cause wheezing.
• CHF- due to edema of airways and congestion of bronchial mucosa
• COPD- in amed air ways may be narrowed, or bronchospasm may be present
• Cardiomyopathies, pericardial diseases can lead to edema around the bronchi
• Lung cancer--due to obstruction of airways (central tumor or mediastinal invasion)
fi
fi
fl
 Diagnosis of Asthma:
The diagnosis of asthma is predominantly clinical and is based on the combination of
history, lung function and 'other" tests.
1. Pulmonary function tests (PFTs) used for diagnosis. They show an OBSTRUCTIVE
PATTERN : decrease in expiratory ow rates, decreased FEV1, and decreased FEV1/
FVC ratio (<0.70).
2. Spirometry before and after bronchodilators can con rm diagnosis by providing
REVERSIBLE airway obstruction. If inhalation of a bronchodilator (Beta2-agonist) results
in an increase in FEV1 or FVC by at least 12%, air ow obstruction is considered
reversible.
3. Peak ow (peak expiratory ow rate)-useful measure of air ow obstruction. Patients
should self-monitor their peak ow.
4. Bronchoprovocation Test :
a. May be useful when asthma is suspected but PFTs are nondiagnostic.
b. Measures ease with which airways narrow in response to stimuli (hyperresponsiveng
c. Measures lung function before and after inhalation of increasing doses of
methacholine (muscarinic agonist); hyperresponsive airways develop obstruction at
lower doses.
The diagnosis may be supported by the presence of peripheral blood eosinophilia or
atopy demonstrated by skin-prick tests or measurement of total and allergen-speci c
IgE, X-ray appearances are often normal.

Investigations
in suspected asthma.
• Blood tests: Full blood count, IgE,
radioallergosorbent test (RAST) it a
speci c allergy is suspected
• Skin prick test to allergens: tree pollen,
grass pollen, dog, cat, horse, feather, HDM,
aspergillus fumigatus
• CXR
• HRCT
• Peak expiratory ow (PEF) and PEF
fl
homework
• Spirometry
fi
fi
• Full lung function test with reversibility
• Exhaled nitric oxide (FeNO)
fl
• Methacholine provocation test
• Sputum analysis
fl
fl
fl
• Nose and throat examination
fl
• Bronchoscopy
fl
Diagram of PEF chart in poorly controlled asthma showing diurnal variation
fi
 Management of Asthma:
1. Setting goals
2. Self-management
3. Avoidance of aggravating factors
The stepwise approach to the management of asthma :
Step 1: Regular preventer
The initial therapy for a patient diagnosed with asthma would be a lowdose inhaled
glucocorticoid (ICS).For adults, a starting dose equivalent to beclometasone
dipropionate (BDP) 400 microgram per day is reasonable,
although higher doses may be required in smokers.
Step 2: Initial add-on therapy
If the asthma remains poorly controlled despite regular preventer therapy, the next step
should be addition of a long-acting beta agonist (LABA), This should be done via a
combination ICS/LABA Inhalers to prevent inadvertent administration of LABA
monotherapy and risk of asthma death. Combination ICS/CABA inhalers
containing the fast-acting LABA formoterol can be used as a maintenance and reliever
(MART) inhaler allowing for auto-titration of therapy in response to symptoms.
Step 3: Additional add on therapies
If asthma control remains poor despite initial add-on therapy, the patient should have a
detalled asthma review. There are a number of options to consider at this stage:
* If there has been no response to the LABA, then it should be stopped and an Increase
of the ICS to a medium dose (800 micro g) considered.
* If there is bene t from the LABA, but control is poor then the ICS should be Increased
to a medium dose, alternatively trial of a leukotriene antagonist (LTRA) or a slow-release
theophylline preparation should be considered.

Step 4: High-dose therapies

In adults, the dose of inhaled glucocorticold should be trialled up to a high dose (2000
micro g BDP) (or equivalent) daily. Trials of LTRA, long-acting antimuscarinic agents
(LAMA), theophyllines or a slow-release oral Beta2-agonist may be considered. If the
fi
trial of add-on therapy Is ineffective, it should be discontinued.
Step 5: Continuous or frequent use of oral glucocorticoids
At this stage, oral prednisolone (usually administered as a single daily dose in the
morning) should be prescribed at the lowest dose necessary to control symptoms and
the patients should be referred for specialist severe asthma assessment. These patients
should be considered for biologic therapy to minimise long-term harm from oral
glucocorticoids. Omalizumab (anti-IgE) therapy may be considered for those patients
with severe IgE-driven atopic asthma.
 Exacerbations of asthma
✓ The course of asthma may be punctuated by exacerbations with increased
symptoms, deterioration in lung function, and an increase in airway in ammation.
Exacerbations are most commonly precipitated by viral infections but moulds, pollens
(particularly following thunderstorms) and air pollution are also implicated.
✓ Most attacks are characterised by a gradual deterioration over several hours to days
but some appear to occur with little or no warning: so-called brittle asthma. An
important minority of patients appear to have a blunted perception of airway narrowing
and fail to appreciate the early signs of deterioration.
Management of mild to moderate exacerbations
✓ Doubling the dose of inhaled glucocorticolds does not prevent an impending
exacerbation. Short courses of at least 5 days of 'rescue' glucocorticoids (prednisolone
40-50 mg/day) are therofore often required to regain control. Tapering of the
glucocorticoid dose to withdraw treatment is not necessary, unless It has been given
for more than 3 weeks.
Indications for “rescue” courses Include:
* symptoms and PEF progressively worsening day by day, with a fall of PEF below
75% of the patient's personal best recording.
* onset or worsening of sleep disturbance by asthma.
* persistence of morning symptoms until midday.

Management of acute severe asthma

• Measurement of PEF is mandatory, unless the patient is too Ill to cooperate.
• Arterial blood gas analysis is essential for those patients with life-threatening or near-
fatal asthma to determine the PaCO2, a normal or elevated level being particularly
dangerous.
• A chest X-ray is not immediately necessary, unless pneumothorax is suspected.
Treatment includes the following measures :
❖ Oxygen. Controlled supplemental oxygen should be administered to maintaln Sa02
94%-98%. Falure to achieve appropriate oxygenation is an indication for assisted
ventilation.
fl
❖ High doses of inhaled bronchodilators. Short-acting Beta2-agonists are the agent of
choice. They can be administered either via multiple doses of a metered-dose inhaler via
a spacer device, or via a nebuliser driven by oxygen. Ipratropium bromide provides
further bronchodilator therapy and should be added to if there is a failure to respond to
salbutamol or in life-threatening attacks.
❖ Systemic glucocorticoids. These reduce the in ammatory response, reduce mortality,
subsequent hospital admission and requirement for bronchodilators. They should be
fl
administered to all patients with an acute severe attack. They can usually be
administered orally as prednisolone but intravenous hydrocortisone may
be used in patients who are vomiting or unable to swallow.
❖ Potassium supplements may be necessary to counteract hypokalaemia caused by
repoated doses of beta-agonists. If patients fail to improve, a number of further options
may be considered, Including “intravenous magnesium” for patients with life-threatening
or near-fatal attacks and “intravenous aminophylline. PEF should be recorded 15-30
minutes after starting therapy and thereafter according to response every 4-6
hours and pulse oximetry should be monitored to ensure that Sa02 94%-98% is
maintained.
 ‫ِ‬
‫واشف جراحهم وكن لهم ناصرا ومعينا‬ ‫اللهم أغث إخواننا في فلسطني 🇸🇵 واحقن دمائهم‬
‫وحافظا وظهيرا برحمتك يا أرحم الراحمني… 🤲‬

‫‪19 October 2023‬‬