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Treatment of asthma; basics can save lives!

Treatment of asthma; basics can save lives!

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  • 1. Dr M. Dikgang
  • 2.  Chronic inflammatory disease of airways Increased responsiveness of tracheobronchial tree Multiplicity of stimuli Episodic disease Narrowing of airways (acutely and gradually), relieved spontaneously or after therapy.
  • 3. Risk Factors (for development of asthma) INFLAMMATIONAirwayHyperresponsiveness Airflow Obstruction Risk Factors Symptoms (for exacerbations)
  • 4.  Asthma is one of the most common chronic diseases worldwide —160 million patients suffer from asthma Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in children in China A major cause of school/work absence An overall increase in severity of asthma increases the pool of patients at risk for death
  • 5. Worldwide Variation in Prevalence ofAsthma SymptomsInternational Study ofAsthma and Allergies inChildren (ISAAC)Lancet 1998;351:1225
  • 6. Environmental Genetic factors factors MixedAtopic factors Non-asthma atopic/idiosyncratic asthma Early onset Late onset
  • 7. Stimuli: Allergens (mites, fur, feathers,molds etc) Pharmacological (NSAIDS, B-blockers etc) Environmental (NO2, sulphur dioxide) Occupational (wood/vegetable dust,pharmaceuticals etc) Infections (viruses-RSV, para-influenza) Exercise Emotional stress (vagal efferent activity, endorphins)
  • 8.  Gross overdistention of lungs, non-collapsible Gelatinous plugs of exudate in bronchial branches, down to terminal bronchioles Hypertrophy of bronchial smooth muscle Hyperplasia of mucosal & submucosal blood vessels Mucosal oedema Thickening of basement membrane Eosinophilic infiltrates in the bronchial walls
  • 9.  History and patterns of symptoms Physical examination Measurements of lung function Measurements of allergic status to identify risk factors
  • 10.  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
  • 11.  Lung function tests- FEV1/FVC ratio (<70%or normal), PEFR Bronchodilator test- reversibility (>15% improvement in FEV1) CXR Sputum (thick, with eosinophils + Charcots- Leyden crystals), blood (IgE levels, eosinophilia) Allergy tests- skin, inhalants, catecholamines etc.
  • 12. Asthma COPDcannot be fully prevented can be prevented can be fully controlled cannot be fully reversed does not progress is progressive
  • 13. COPD and Asthma are different diseases! Asthma COPD Allergic Small airway inflammation of COPD narrowing airways & & Asthma Bronchospasm Hyper- (15%) & responsiveness Airway collapse Bronchospasm Maintain Control inflammation bronchodilatation with ICS with regularMinimal bronchodilator bronchodilator
  • 14. History COPD AsthmaSmoker or ex- Nearly always VariablesmokerOnset Usually > 40 Most < 30 years yearsBreathlessness Gradual and Paroxysmal progressiveChronic cough Common Infrequentwith sputum
  • 15. Investigation COPD AsthmasFEV1 Always reduced VariableDaily variation in Minimal ―Morning dip‖PEF + day-to-dayReversibility <15% >15%
  • 16. To effectively controll asthma by…A. Suppressing and reversing inflammationB. Treating bronchoconstriction and related symptoms
  • 17.  Life-threatening medical emergencies Treatment is often most safely undertaken in a hospital or hospital-based emergency department
  • 18. Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if neededGood Response Incomplete/Poor Response Respiratory FailureObserve for at Add Systemic Glucocorticosteroids least 1 hour Good Response Poor Response If Stable, Discharge to Discharge Admit to Hospital Admit to ICU Home
  • 19. Goals of Long-term Management Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation Prevent asthma mortality
  • 20. Uncontrolled Controlled (mild Partly controlled (moderate- Characteristic intermittent) (mild persistent) severe (All of the following) (Any present in any week) persistent) None (2 or less / More thanDaytime symptoms week) twice / week Limitations of 3 or more None Any features of activities partly Nocturnal controlled symptoms / None Any asthma awakening present in Need for rescue / None (2 or less / More than any week“reliever” treatment week) twice / week < 80% predicted or Lung function Normal personal best (if (PEF or FEV1) known) on any day Exacerbation None One or more / year 1 in any week
  • 21.  Preventers - anti-inflammatory Relievers - short acting bronchodilators that provide rapid relief of symptoms Controllers - sustained bronchodilator action with unproven or mild anti-inflammatory action
  • 22. Classification of drugs used in the maintenance treatment of asthma PREVENTERS CONTROLLERS RELIEVERS Anti-inflammatory Sustained broncho- For quick relief of action to prevent dilator action but weak symptoms and use in asthma attacks or unproven anti- acute attacks as p.r.n. inflammatory effect dose onlyInhaled Long-acting ß2 Short-acting ß2corticosteroids agonists agonists Beclomethasone Salmeterol Salbutamol Budesonide Formoterol Fenoterol Fluticasone Methylxanthines Terbutaline Flunisolide Hexoprenaline Triamcinolone Sustained-release Orciprenaline theophyllinesOral Anti-cholinergicscorticosteroids Leukotriene IpratropiumPrednisone receptor Short-actingPrednisolone antagonists** theophyllinesMethylprednisolone Montelukast Zafirlukast ** Provisional categorisation pending further data
  • 23. MILD Increasing Severity SEVEREINTERMITTENT Inhaled corticosteroids > 1000 µg/day Inhaled (BDP corticosteroids equivalent) 500 - 1000 +/- Inhaled µg/day corticosteroids Oral (BDP corticosteroids 200 - 500 µg/day equivalent) (BDP equivalent) +/- + Long-acting ß2 + Long-acting ß2 Long-acting ß2 agonist agonist (preferred) agonist +/- or SR theophyllines (preferred) SR Inhaled and/or or theophyllines corticosteroids SR Inhaled 200 - 500 µg/day theophyllines corticosteroids 500 (BDP - 1000 µg/day (BDP equivalent) equivalent) Refer pulmonologist ß2 agonists prn ß2 agonists prn ß2 agonists prn ß2 agonists prn ß2 agonists prn may be required 4-6 x/day LTRA? LTRA
  • 24.  A convenient and reliable multi-dose device New propellant is HFA (ozone-friendly) Rapidly moving, short- duration plume Impaction of spray in oropharynx likely Evaporating spray feels cold 70% of dose lodges in pharynx and much may be swallowed, 15 -20% in lung
  • 25.  Remove mouthpiece cap Shake inhaler (suspensions only) Breathe out Place actuator mouthpiece between lips Fire while breathing in slowly and deeply Continue to inhale Hold breath (for 10 sec)
  • 26.  CRUCIAL ERRORS  Firing device at or after end of inhalation  Stopping inhalation / inhaling through nose (―cold Freon‖ effect)  Bizarre errors (e.g. not removing mouthpiece cap) NON-CRUCIAL ERRORS  Firing device before start of inhalation  Fast inhalation  No breath-hold / short breath-hold  Failure to shake inhaler (suspensions only)
  • 27.  Useful for small children (used with snug-fitting face mask) Useful in improving inhaled steroid deposition in those with difficulty co- ordinating firing of pMDI during or before inhalation Shake inhaler (suspensions only) Insert pMDI into spacer Breathe out Fire while (or before) breathing in slowly and deeply Continue to inhale Hold breath (for 10 sec) Repeat with second puff
  • 28.  Remove cover (device-specific) Prepare device / load dose (device-specific) Pierce capsule (single-dose devices only) Breathe out gently Place mouthpiece between lips Inhale deeply and quickly* Breath-hold (device-specific) Replace cover and store in dry cool environment
  • 29. Montelukast - SingulairZafirlukast - AccolateAdvantages:• Unique mode of action• Anti-inflammatory – no bronchodilator effect• Very simple dosing: taken by mouth; single dose strength for children, another foradults• Safe• Use: – Add to inhaled corticosteroids – Monotherapy in mild allergic asthma (children)Disadvantages:• Poor efficacy (not better than theophylline for most endpoints especially in adults( More useful in children)• Expensive !
  • 30. DISADVANTAGESADVANTAGES  Bulky, inconvenient Easy to use correctly once Electricity supply usually needed prepared: relaxed tidal  Preparation and assembly a problem, breathing especially for the elderly? Convenient way of  Long treatment times delivering high doses Patients find them  Cleaning / contamination issues reassuring  Expensive Dose control possible in  Patients rely on them instead of using sophisticated devices controller medications No propellants needed  Their use can delay patients presenting to emergency departments and lead to asthma deaths (false sense of security)  They are air and not oxygen-driven, so do not correct hypoxia
  • 31. Reasons for poorpatient adherence to treatment  Misunderstanding about need for both long-term preventive and quick-relief medications  Difficulty with inhaler devices  Fear of side effects or addiction  Cost of medication  Dislike of medication
  • 32. Follow-upAt regular visits (every one to six months): Monitor asthma control – Review symptoms – Measure lung function – Assess compliance Modify the treatment plan – Reinforce compliance – Adjust medications
  • 33.  Kasper et-al. Harrison’s Principles of Internal Medicine, 16th edition: 2005; McGraw-Hill, New York, USA: pp1508-1516 Zhiwen Zhu. Pulmonary & Critical Care Medicine, 1st Affiliated Hospital of Sun Yat-Sen University, China