BRONCHIAL ASTHMA

Prof.Quazi Tarikul Islam

FCPS,FACP,FRCP(Glasg), FRCP (Edin)
Professor
Department of Medicine
Popular Medical College
 Introduction
Bronchial Asthma is a very common clinical condition
and is the most common cause of hospitalization
during winter in our country.

Bronchial Asthma is defined by the National Institutes

of Health (NIH), USA's consensus panel as 'a chronic
reversible inflammatory disorder of the airways in
which many cells and cellular elements play a role, in
particular, mast cells, basophils, T lymphocytes,
macrophages, neutrophils and epithelial cells. In
susceptible individuals, this inflammation causes
recurrent episodes of wheezing, breathlessness, and
chest tightness, particularly at night or in the early
morning.
 Prevalence:
Internationally Asthma prevalence varies
from 1-30% across nations.

The prevalence increases with increased

urbanization and affluence.

Increases in asthma mortality in recent

years have been noted in Australia,
Canada, United Kingdom, Germany and
Switzerland
Male : Female ratio
Before 10 years 2:1
Between 18 to 54 years 1:2
7 to 10% of children (many outgrow this
condition)
5% of adult population (remission less
common)
In 30% of asthmatics recover before
adolescence

50% of cases develop childhood

 Mortality/Morbidity:
Overall, the death rate from acute
asthma has increased from 13
deaths per million in 1982 to 19
deaths per million in 1991.

This is a remarkable 40% increase

in just 10 years.
 Aetiology:
Aetiology of Asthma is multifactorial in origin.
.
Atopy:
The genetic predisposition for the development of
an IgE-mediated response to common
aeroallergens, is the strongest identifiable
predisposing factor for the development of asthma.

Environment:
A variety of 'triggers' may initiate or worsen an
asthma attack.
Genes:
In this regard, several T cell associated genes
have been linked with susceptibility to asthma
or related traits, including the gene encoding
IL-4 and its receptor (IL-4R), the IL-13 gene,
and the IL-10 gene.
A genetic role in asthma has long been suspected
6.5% of families in which neither parent has
asthma have a child with asthma.
28% of families in which one parent has
asthma have a child with asthma.
63% of families in which both parents have
asthma have at least one child with asthma.
Autonomic nervous system:

Idiosyncratic asthma is a result of

neurological imbalances in the
autonomic nervous system (ANS) in
which the alpha and beta adrenergic
as well as the cholinergic sites of the
ANS are not properly coordinated.
Triggers of Bronchial Asthma
Exposure to a variety of
occupational irritants
Vapors,
Dust,
Gases,
Fumes,
Tobacco smoke,
Air pollution.
Most common allergens are
Microscopic droppings of dust
mites and cockroaches,
Airborne pollens and molds,
Plants and plant proteins,
enzymes, and
Pet dander (minute scales of
hair, feathers, or skin).
 Drugs:
Beta-blockers,
Aspirin,
Ibuprofen,
Indomethacin,
Naproxen.

Others react to sulfites( chemicals

commonly used to preserve foods
such as tuna, salads, dried apples
and raisins, and beverages such as
lemon juice, grape juice, and wine).
Other Factors:
Sinus infections,
Gastro esophageal reflux
disease (GERD),
Pregnancy,
Menstruation,
Emotion,
Stress.
 Pathophysiology
Asthmatic Symptoms Result from:
1. Mast cell releases mediators
2. Inflammatory cell infiltration of airway tissue
3. Bronchospasm
4. Edema (swelling) of the airway tissues
Fig02a.gif

5. Increased thick mucus and mucous plugs

6. Bronchial obstruction causing symptoms
7. Hyper-responsiveness of the airway
8. Fig02a.gif
Possible remodeling of the airway (permanent
damage)
Inflammatory Cells and Mediators
Inflammatory and Bronchoconstriction Events of the Early Phase of
an Acute Asthmatic Response to Allergen Exposure
Inflammatory and Bronchoconstriction Events of the Late Phase
of an Acute Asthmatic Response to Allergen Exposure
The Early and Late Asthmatic Response
following Allergen Challenge
Classification of Asthma by Cause
•Extrinsic, allergic asthma
•Intrinsic, non-allergic asthma
•Mixed-type asthma
•Exercise-induced asthma
•Occupational asthma
•Cough-variant asthma
•Nocturnal asthma
•Aspirin-induced asthma
•Potentially fatal asthma
•Coexistent asthma and COPD
•Cardiac asthma
•Factitious asthma
•Stress-induced asthma
 Risk Factors For Asthma
•Living in a large urban area, especially the inner city,
which may increase exposure to many environmental
pollutants
•Exposure to secondhand smoke
•Exposure to occupational triggers, such as chemicals
used in farming and hairdressing, and in paint, steel,
bronchial challenge - monitoring - capnography - asthma.htm

plastics, and electronics manufacturing

•Having one or both parents with asthma
•Respiratory infections in childhood
•Low birth weight
•Obesity
•Gastroesophageal reflux disease (GERD)
Symptoms of Bronchial Asthma:
Wheezing (
usually begins suddenly
is episodic
may be worse at night or in early morning
aggravated by exposure to cold air
aggravated by exercise
aggravated by heartburn (reflux)
resolves spontaneously
relieved by bronchodilators
Cough with or without sputum production
Shortness of breath that is aggravated by
exercise
Breathing that requires increased work
Intercostals retractions
 Differential Diagnosis
In Children:
•Inhaled foreign body (e.g. peanut)
•Narrow or floppy trachea/larynx
•Cystic fibrosis
•Immunodeficiency
•Tumors, lymph nodes in chest pressing on airway
•Blood vessels pressing on airway
•Vocal cord dysfunction
•Pneumonia, bronchiolitis, congenital defects
•Congenital heart disease
Differential Diagnosis (cont.)
In Adults:
•Chronic obstructive pulmonary disease (COPD)
•Vocal cord dysfunction
•Congestive heart failure / irregular heart rhythm
•Tumors of the lung
•Immunodeficiency
•Pulmonary embolism
•Medication induced cough (ACE inhibitors)
•Other diseases of lung tissues
 Investigations:
S Spirometry
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SPIROMETRY

FEV1,VC
Investigations (cont.):
Peak Expiratory Flow

Different types Peak Flow Meter

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Investigations (cont):
Bronchial Provocation
Other Tests
Chest x-rays
Allergy testing, either by skin
testing or by measuring antibodies in
the blood
X-rays of the sinuses is often done
to exclude sinusitis as a factor
Rhinolaryngoscopy .
Arterial blood gas
Eosinophil count
 Classification of Asthma Severity Before Treatment:

Severity Days with Nights with PEFR PEFR

symptom symptoms variability
Severe Continual Frequent <=60% 30%
persistent
Moderate Daily >=5/month 60-80% 30%
persistent
Mild 3-6/week 3-4/month >=80% 20-30%
persistent
Mild <=2/week <=2/month >=80% <20%
intermittent
 Immediate assessment
of
Acute Severe Asthma
Features of severity
Pulse rate >110
Pulsus paradoxus
Unable to speak in sentences
PEF <50% of expected
 Immediate assessment
of
Acute Severe Asthma
Life-threatening features
Cannot speak
Central cyanosis
Exhaustion,confusion,reduced conscious level
Bradycardia
Silent chest
Unrecordable PEF
 Goals of Management of Asthma
1. Control chronic symptoms
2. Perform usual school or work activities with few
limitations
3. Prevent exertion-related or exercise-related
asthmatic symptoms
4. Avoidance of emergency room visits and
hospitalizations
5. Enjoy full night's sleep without respiratory
distress
6. Have a clear chest in the morning without chest
tightness or shortness of breath
7. Optimize pulmonary function
8. Tolerate medications without side effects
Drugs used in Bronchial Asthma:
A.Relievers (Bronchodilators)
Short acting beta-2 Agonists
Salbutamol
Terbutaline
Metaroterenol

Short acting Aminophyline

Ipratropium bromide
Drugs used in Bronchial Asthma(cont.):
B.Preventers (Anti-inflammatory medicine)
Corticosteroids
Beclomethasone Flunisolide
Budesonide Momentasone
Fluticasone Hydrocortisone(inj.)
Triamcinolone Prednisolone(oral)
Sodium
Cromoglycate
Nedocromil Sodium
Leukotriene Modifier
Zileuton Montelukast
Zafirlukast Pranlukast
Drugs used in Bronchial Asthma(cont.):
C.Protectors (Symptom controllers)
Long acting beta-2 Agonists
Salmeterol
Fenoterol
Rimeterol
Bitolterol

Long acting Theohylline

Sustained Release Salbutamol

 Newer Drugs:
Other anti-inflammatory Drugs:
Hydroxychloroquine
Methotrexate
Troleandomycin

Immunotherapy

Anti-IgE monoclonal antibodies

 Treatment Steps

5 Addition of regular
oral steroid therapy

4 High-dose inhaled steroids

and regular bronchodilators
High dose inhaled steroids or low-
3 dose inhaled steroids plus long-
acting inhaled beta-2 agonist

2 Low-dose inhaled steroids (or other anti-

inflammatory agents)
Occasional use of inhaled short-acting beta-2
1 adrenoceptor agonists
 Treatment Steps
(Economic Schedule)
Oral steroid PLUS
4 (Prednisolone) single
morning dose (5-20mg)
Step-3

Oral plain Aminophylline/

3
Theohylline 2-3 times daily PLUS
PLUS Long acting Salbutamol 2- Step-1
8 mg 2 times daily

2 Oral plain Aminophylline/Theohylline PLUS

2-3 times daily Step-1
Short acting beta-2 agonist tablet/syrup (Salbutamol;

1 for adults 2-4 mg,for children 0.15 mg/KBW/dose) as

required
Start high and step down
Occasional temporary
step-ups will be needed
to control exacerbations
Consider step-down if good
symptom control for 3
months or more
Only think of withdrawing anti-
inflammatory treatment if patient
well for at least 6 months
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Spacer is indicated who are unable to use inhaler
properly specially in children and elderly.

Different types of Spacer

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 MANAGEMENT OF ASTHMA ATTACKS
(Hospital-based Care)
Initial Assessment
History,Physical exam (auscultation,use of accessory
muscles,heart rate,respiratory rate) & Investigations (PEF or
FEV1, Oxygen saturation,arterial blood gas analysis)

Initial Treatment
Inhaled short acting beta-2 agonist,usually by nebulization,one
dose every 20 minutes for I hour
Oxygen to achieve oxygen saturation >90% (95% in children)
Systemic corticosteroids
Sedation is contraindicated in the treatment of attacks
 Repeat Assessment
PFT,PEFR,SaO2 & other tests as needed

Severe episode
Moderate Episode On assessment
On assessment •PEFR <50%of predicted/personal best
•PEFR 50-80% of predicted/personal •Physical exam: severe symptoms at rest,
best chest retraction
•Physical exam: moderate •High risk patient
symptoms,accessory muscle use •No improvement after initial treatment

Treatment
•Inhaled beta-2agonist every 60 minutes
•Consider corticosteroid
•Continue treatment 1-3 hours,provided
there is improvement
Treatment
•Inhaled beta-2agonist, hourly or
continuous +inhaled anticholinergic
•Oxygen 40% (5L/min)
•Systemic corticosteroid
•Consider subcutaneous, intramuscular
or intravenous beta-2 agonist
 If good response:
On assessment
•Response sustained 60 minutes after last treatment
•Physical exam: normal
•PEFR >70%
•No distress
•Oxygen saturation >90% (95% in children)

Discharge home
•Continue treatment with inhaled beta-2 agonist
•Consider,in most cases,corticosteroid tablets or syrup
•Patient education:Take medicine correctly,Review action
plan,Close medical follow up
If Incomplete Response Within 1-2 Hours
On assessment
•High-risk patient
•Physical exam: mild to moderate symptoms
•PEFR >50% but
•Oxygen saturation not improving

Admit to Hospital
•Inhaled beta-2 agonist +inhaled anticholinergic
•Systemic corticosteroid
•Oxygen
•Consider intravenous aminophylline
•Monitor PEFR,Oxygen saturation,pulse.
 If Poor Response Within 1 Hour
On assessment
•High-risk patient
•Physical exam:symptoms severe,drowsiness,confusion
•PEFR <50%
•PCO2 >45 mm Hg
•Oxygen saturation <90%

Admit to ICU
•Inhaled beta-2 agonist +inhaled anticholinergic
•Inhaled corticosteroid
•Consider subcutaneous, intramuscular intravenous beta-2 agonists
•Oxygen
•Consider intravenous aminophylline
•Possible intubation and mechanical ventilation
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Therapies not recommended during acute attack
Sedatives (strictly avoid)
Mucolytic drugs (may worsen cough)
Chest physical therapy (may increase patient
discomfort)
Hydration with large volumes of fluid for adults
and older children (may be necessary for younger
children and infants)
Antibiotics (do not treat attacks but are indicated for
patients who also have pneumonia or bacterial
infection such as sinusitis)
Antihistamines (has no helpful effect on asthma
itself,but can be given to prevent allergic rhinitis)
 Rescue Steroid Therapy
Rescue course of steroid tablets may be
needed to control exacerbation of asthma
at any step.

Dose: Adults:30-60 mg/day

Children:1-2 mg/KBW/day

Duration:Until 2 days after control is re-established

Indication of Rescue Steroid Therapy
Symptoms and PEF progressively worsen day
by day.
Fall of PEF below 60% of the patient’s
personal best recording.
Onset or worsening of sleep disturbance by
asthma
Persistence of morning symptoms until midday
Progressively diminishing response to an
inhaled bronchodilator
Symptoms severe enough to require treatment
with nebulized or injected bronchodilators
Prevention of Flares of Asthma:
•Know the type of asthma and its triggers.
•Know the allergies and avoid unnecessary exposures.
•Have a written list of emergency instructions.
•Keep the follow-up appointments as recommended.
•Never run out of medications.
•Be compliant with doctor's recommendation.
•Don't smoke or allow to be exposed to cigarette
smoke.
•Reduce exposure to known asthmatic triggers at home,
work, school and recreation.
•Monitor asthma (symptoms & peak flow rates) - don't
deny problems.
•Always have emergency medications on hand at home
and when traveling.
•Call doctor when asthma first begins to flare
Prevention of Allergic Asthma
General Dietary Changes
Eat more Oily Fish (Fish Oils)
A diet rich in Magnesium
A diet rich in Selenium
A diet rich in Vitamin B6
A diet rich Vitamin B12
And Last but certainly NOT least
Sinus & Nasal Cleansing - Drug Free Relief for
Asthma and Allergy Symptoms
Treatment of Exercise Induced Asthma
Treatment of Exercise Induced Asthma

•Inhaled medications taken prior to exercise are

helpful in controlling and preventing exercise-
induced bronchospasm.
• The medication of choice in preventing EIA
symptoms is a short-acting beta2agonist
bronchodilator spray used 15 minutes before
exercise.
•These medications, which include salbutamol,
pirbuterol, and terbutaline, are effective in 80-90
percent of patients, have a rapid onset of action,
and last for up to four to six hours.
•These drugs can also be used to relieve
symptoms associated with EIA after they occur.
Prevention of Occupational Asthma
Once the cause is identified, exposure
levels should be reduced. For instance, a
worker could be moved to another job
within the plant.
Employers might consider pre-screening
potential employees with lung function
tests and then continue to test for
symptoms after certain periods on the
job once the worker has been hired to
ensure that he or she has not developed
asthma.
Work areas should be closely monitored
so that exposure to asthma-causing
substances is kept at the lowest possible
levels.
Complications:

Respiratory fatigue
Pneumothorax
Complications from overuse of
medications
 Adverse Effects of Drugs
Drugs Adverse effects
B Palpitations
Beta-2 agonist Headache
Nausea
Tremors
Aminophylline/ •Gastrointestinal symptoms: stomach
Theophylline ache, nausea, vomiting, diarrhea
•Nervous system symptoms: headache,
irritability, difficulties concentrating
at work or in school, insomnia,
jitteriness, convulsions
•Cardiac symptoms: fast heart rate,
palpitations, irregular heart rate
Adverse Effects of Drugs (cont.)
Drugs Adverse effects
Ipratropium Dry mouth,
Bromide Blurring of vision,
Palpitations

Nedocromil Sodium Unpleasant taste,

Coughing,
Wheezing,
Sore throat,
Running nose,
Nausea,
Dizziness.
Adverse Effects of Drugs (cont.)
Drugs Adverse effects
Leukotriene Modifiers Headache,
Nausea,
Stomach upset,
Pain,
Fever,
Muscle ache,
Fatigue,
Sore throat,
Laryngitis
Liver enzyme elevation.
Adverse Effects of Drugs (cont.)
Drugs Adverse effects
Corticosteroids Weight gain,Water retention,
(In case of long Filling out or rounding of the face,
term use) Osteoporosis (weak bones),High
blood pressure,Damage to hip
bone,Inhibition of linear growth in
children,Muscle weakness,
Cataracts,Glaucoma,Gastric
ulcer,Thinning of skin,Increased hair
growth in women,Acne,Loss of
hair,Stretch marks,Increased
bruising of skin,Personality
changes,Menstrual changes,
Depression,Increased blood sugar.
 Prognosis:
•Approximately half the children diagnosed with
asthma in childhood outgrow their disease by late
adolescence or early adulthood and require no
further treatment.
•Patients with poorly controlled asthma develop
long-term changes over time, I.e, with airway
remodeling. This can lead to chronic symptoms
and a significant irreversible component to their
disease.
•Many patients who develop asthma at an older
age also tend to have chronic symptoms.
 Conclusion
Bronchial asthma is a common illness of the
lungs affecting about five percent of the
population.
It has increased in frequency and in mortality
for reasons that are not clear.
New knowledge of the importance of
inflammation in asthma has lead to newer
more effective treatment.
There is no reason for this illness to have fatal
outcomes or require expensive hospital care.
Once the patient recognizes that he or she can
self manage asthma effectively with only
occasional help by their doctor, a major
improvement in health and quality of life
always follows.
 Summary
Although no cure exists for asthma, excellent
treatment is available.

We learn more about asthma every year and

newer, more effective and safer drugs are
always being developed.

As a result, most asthmatics live normal,

productive lives.

Research is continuing and the outlook is bright.