The surface area of the lungs is roughly the samesize as a tennis court.
The capillaries in the lungs would extend 1,600kilometres if placed end to end.
A person at rest usually breathes between 12 and15 times a minute.
The breathing rate is faster in children andwomen than in men.
DRUGS FOR BRONCHIALASTHMA Dr. V.SATHYANARAYANAN M.D PROFESSOR OF
BRONCHIAL ASTHMA Hyperresponsiveness of tracheo-bronchial smooth muscle resulting in narrowing of bronchial tree Wheezing attacks polygenic Primarily inflammatory condition
Mediators in Asthma Mediators released are > 100 in number histamine, TNFa - immediate Prostaglandins, leukotrienes, PAF – within min Interleukins, TNFa – /over hrs
Symptoms of Asthma• Wheezing• Cough, especially at night• Chest tightness• Shortness of breath• Characteristically occur or worsen at night, with exercise, with viral infections, or with exposure to dust, animals, or smoke
JOKE WITH ASTHMA Matthew sets up Andrew to go on a blind date with a friend of his. But Andrew is a little worried about going out with someone he has never seen before. “What do I do if she’s ugly?” says Andrew, “I’ll be stuck with her all night.” “Don’t worry.” Matthew says. “Just go up to her door and meet her first. If you like what you see, then everything goes as planned. If you don’t, just shout Aaauuuggghhh! and fake an
JOKE WITH ASTHMA So that night, Andrew knocks at the girl’s door, and when she comes out he is awe-struck at how beautiful and sexy she is. Andrew’s about to speak when the girl suddenly shouts, “Aaauuuggghhh!”
SALBUTAMOL Beta2 stimulation inc.cyclic AMP relaxation, decreases mediator release Fastest acting , within 5 min, lasts for 2-4 hrs Relieves symptoms Used to abort acute attacks of asthma ADR – tremors, palpitation, restlessness, ankle edema, hypokalemia Orally in severe asthma Regular use – downregulation of receptors
TERBUTALINE Similar to salbutamol Used only for symptomatic relief
BAMBUTEROL Prodrug Hydrolysed by pseudocholinesterase into active drug Release over 24 hrs Indicated in chronic bronchial asthma Single evening dose 10 -20 mg
SALMETEROL Long acting beta2 agonist Slow onset of action Used by inhalation Twice a day schedule For maintenance therapy and nocturnal asthma
FORMOTEROL Long acting beta2 agonist Acts for 12 hrs when inhaled Fast acting as well Used as a Regular twice a day schedule for round the clock bronchodilatation.
OTHER BETA AGONISTS Adrenaline, ephedrine, isoprenaline Less safe – cause cardiac arrhythmias
Worried Patient Patient: Doctor, when I press my leg it hurts. Then when I press my chest it hurts, when I press my head it hurts, and when I press my stomach it hurts. Im worried doc, whats wrong with me? Doctor: Easy straightforward, you have a sore finger!
THEOPHYLLINE Xanthine alkaloid Good bronchodilator Inhibit phosphodiesterase 5, release Ca, block adenosine receptors CNS stimulant, increases HR, Diuretic, increases acid secretion, dilate bronchi Also used in COPD Has low therapeutic index Use has declined because of safety
THEOPHYLLINE - ADR Insomnia, nervousness, flushing Tremors Vomiting Palpitation Arrhythmias, seizures in high doses
THEOPHYLLINE – DRUGINTERACTIONS Microsomal enzyme inhibitors increases toxicity Enzyme inducers decrease levels Theophylline enhances the effects of furosemide, sympathomimetics, hypoglycemics PK – elimination changes 1st order to 0 order Has low therapeutic index – need monitoring
USES Bronchial asthma COPD Apnoea in premature infant
ANTIMUSCARINICBRONCHODILATORS Ipratropium bromide, oxitropium, tiotropium Block M3 receptors Inhaled less systemic effects Slower response Better suited for regular prophylactic use Less effective than salbutamol Useful in COPD, refractory asthma
The Specialist What kind of work do you do? a woman passenger enquired of the man travelling in her train compartment. Im a Naval surgeon, he replies. My word! spluttered the woman, How you doctors specialise these days.
CORTICOSTEROIDS Suppress inflammatory response Do not dilate bronchi Afford complete & sustained relief Decrease disease progression Inhaled steroids – only few ADR Long term systemic therapy – more ADR
CORTICOSTEROIDS Prednisolone – given orally Beclomethasone Fluticasone Budesonide all given by inhalation to minimise systemic side effects
INHALED STEROIDS High topical activity ‘ Step 1’ for all patients Indicated if beta2 agonist required daily ADR – hoarseness of voice, dysphonia, oropharyngeal candidiasis, sore throat Safe during pregnancy > 600 micrograms/day systemic effects C/I - Infection
MAST CELL STABILIZERS Sodium cromoglycate, nedocromil Alternative to inhaled steroids Inhibit degranulation of mast cells – prevent release of mediators Given by inhalation Prevent bronchospasm induced by allergens, irritants, cold air, exercise Other Uses – allergic rhinitis, conjunctivitis ADR- mild, like cough, throat irritation
KETOTIFEN H1Antihistamine Like cromoglycate Orally given ADR – Sedation, dry mouth, weight gain 1-2 mg BD Also used in other allergic disorders
LEUKOTRIENE RECEPTORANTAGONISTS Montelucast, zafirlucast Similar efficacy like low dose steroids Used in prophylaxis alternate to steroids More acceptable in children Effective in aspirin induced asthma Very safe, few side effects- headache, rash rarely cause churg- strauss syndrome 2nd – 3rd line role
ZILUTON 5 Lipoxygenase inhibitor Prevent all LT induced responses Efficacy similar to LT antagonists Limitations – short duration, hepatotoxicity
OMALIZUMAB A monoclonal antbody against IgE Binds to IgE form a complex make IgE not bind to IgE receptors on mast cells and basophils inhibition of allergic response Given S.C once in 2-4 weeks ADR – Well tolerated, pain at the site of inj., allergy Caution – a very small% developed cancers Uses – prophylaxis in patients with moderate to severe asthma >12 years
STATUS ASTHMATICUS Also known as refractory asthma , acute severe asthma May be life threatening A medical emergency URI is mostly the precipitant Other triggers – drugs, stress, allergens, abrupt withdrawal of steroids after prolonged use
A JOKE ON SAVING LIFE In a school in Poland the teacher asks, "Has any of you ever saved somebodys life?“ A little boy raises his arm, "Yes, my little nephews.“ "How did it happen? Tell us!" asks the teacher. The little Polack says, "I hid my sisters birth control pills!"
STATUS ASTHMATICUS Nebulized salbutamol (2.5-5 mg )+ ipratropium (0.5 mg ) intermittent inhalation Intermittent high flow humidified Oxygen inhalation Hydrocortisone hemisuccinate 100 mg i.v stat followed by 100 – 200 mg 4-8 hourly infusion Salbutamol/Terbutaline 0.4 mg i.m/s.c may be added Antibiotics i.v fluids + sodium bicarbonate infusion Intubation and mechanical ventilation, if needed NO SEDATION
Can I call you Little Asthma?Cause you take my breathaway……Tweet Share
CHOICE OF TREATMENT – MILDEPISODIC ASTHMA Symptoms < once daily, normal between attacks Inhaled beta2 agonist at onset of episode – step1 Regular Prophylaxis not required
SEASONAL ASTHMA inhaled cromoglycate or low dose inhal.steroids Regularly 3-4 weeks before and after season Individual episodes – short acting inhal. Beta2 agonist
MILD CHRONIC ASTHMAWITH OCCASIONALEXACERBATIONS Symptoms once daily Regular Low dose inhal. Steroids or cromoglicate – step2 Episode treatment with short acting inhal. Beta2 agonist
MODERATE ASTHMA withfrequent exacerbations Attacks affect activity Occur > 1/day Increasing doses of Inhal. Steroids upto 800 micrograms/day + inhal. Long acting beta2 agonist – step3 Or LT antagonist for steroids Theophylline may be used
SEVERE ASTHMA Continuous symptoms, activity limitation, frequent attacks requiring hospitalisation Regular high dose inhaled steroids ( 800 – 2000 micrograms/ day ) with spacer + Inhaled salmeterol BD Leukotriene antagonist/ Oral theophylline S.R/ oral beta2 agonist/ inhaled ipratropium – step4 Not controlled oral steroids – step5
WARNINGS BETA BLOCKERS even topical or selective may precipitate asthma Can be fatal so contraindicated Overuse of beta2 agonists can cause asthma related deaths
NAEPP Guidelines Classification of Asthma Severity 4 Severe Persistent 3 Moderate Persistent 2 Mild Persistent 1 Mild Intermittent
Asthma Treatment SummaryMild Intermittent Use: salbutamol, Asthma Action PlanMild Persistent Use: salbutamol and Controller medications (low dose steroids, nedocromil, cromolyn, montelukast)Moderate Persistent Use: Combination of medications (low to medium dose steroid plus long acting beta agonist, and/or Leukotriene modifiers)Severe Persistent Use: High dose inhaled steroids, long acting beta agonist, and leukotriene modifier. May need oral steroids
PADDY IN THE CONFESSIONBOX Paddy NcNaughty went to confession : "Bless me, Father, for I have sinned.“ Priest asked "And what is it that you have done, my son?" "I made love to one of the girls in the village.“ "My God!" said the priest, "and which of the village girls did you commit sin with?" "Ah, Father, that I cannot tell."
PADDY IN THE CONFESSIONBOX "And if you will not tell me, then I shall not forgive your sins " "Ah dear!" said Paddy. "Was it Molly OFlaherty?" asked the priest. "No, it was not Molly OFlaherty." "Then was it Flora Fitzgibbons?" "Ah no," said Paddy, "it was not Flora Fitzgibbons."
PADDY IN THE CONFESSIONBOX Was it Maggie Muldoon, then?" persisted the priest. "Ah, sure no, it was not Maggie Muldoon." "Then who in heavens name was it?" "Ah, sure, Father -- that I cannot tell.“ "And if you dont tell me I shall not give you absolution."
PADDY IN THE CONFESSIONBOX "Ah, Father, thats too bad!" said Paddy and walked out of the confessional. His friend, Michael, was waiting outside. He asked "Well, Paddy, did you get your sins forgiven?" "No," said Paddy, "but I got the names of few great girls to fun with "
LAUGHTER BOOSTS IMMUNESYSTEM Young children laugh an average of 300 times a day, while adults average somewhere between 15 to 100 times. The saying that ‘Laughter is the best medicine’ may have some truth to it. Laughing helps to boost the immune system.