I am professionally pharmacist. These slides provide for students who study in pharmacy program. This slides related to describe disease.

2. Definition:
Asthma means “laboured breathing”. It is a broad term used to
refer to a disorder of the respiratory system that leads to
episodic difficulty in breathing.

3.  The national UK guidelines (BTS/SIGN,2009) define asthma
as a “chronic inflammatory disorder of the airways which
occur in susceptible individuals; inflammatory symptoms are
usually associated with widespread but variable airflow
obstruction and an increase in airway response to a variety of
stimuli.

4. The events of asthma are:
 Airway obstruction(reversible)
 Hyper-responsiveness.

5.  Difficult breathing
 Wheezing
 Chest tightness
 Coughing

6. Examples of triggers are:
 Allergens: Pollens, moulds, house dust mite,
animals (dander, saliva and urine)
 Industrial chemicals: paints, hair sprays, penicillin's
 Drugs : Aspirin, ibuprofen and other prostaglandin synthetase
inhibitors(aspirin, ibuprofen, NSAIDs),β-adrenoceptor blockers(Atenolol)

7.  Foods: A rare cause but examples include nuts, fish, seafood, dairy
products, food colors, especially tartrazine, benzoic acid and sodium
metabisulfite
 Environmental pollutants: Traffic fumes. cigarette smoke
 Other industrial triggers: Wood or grain dust, cotton, dust, grain weevils
and mites
 Miscellaneous: Cold air, exercise, hyperventilation, viral respiratory tract
infections, emotion or stress,

8. The two main causes of asthma symptoms are:
1. Airway hyper-responsiveness:
It is an increased tendency of the airway to react to stimuli or triggers to cause
an asthma attack.
2. Bronchoconstriction:
It is a narrowing of the airways that causes airflow obstruction.

9. Types of asthma:
Asthma can be classified according to the underlying pattern of airway
inflammation with the presence or absence of eosinophils in the airways.
It includes
 Extrinsic asthma when an allergen is thought to be the cause of their
asthma. More common in children where triggers, such as dust mite, cause
IgE production.
 Intrinsic asthma develops in adulthood, with symptoms triggered by non-
allergenic factors such as a viral infection, irritants which cause epithelial
damage and mucosal inflammation, emotional upset which mediates excess
parasympathetic input or exercise which causes water and heat loss from
the airways, triggering mediator release from mast cells.

11.  Immediate reaction includes
 Mast cell components are released as a result of an IgE antibody-mediated
reaction on the surface of mast cell.
 Histamine and other mediators of inflammation are released from mast cells
for example
 Leukotriene's (C4, D4, E4) Bronchoconstriction and also causes mucus
gland to hyperactive and start producing mucous
 Prostaglandins, Vasodilation and causes more fluid to come out and
cause wall to swell up
 Bradykinnins
 Adenosine as well as
 Various chemotactic agents that attract eosinophils and neutrophils.

12.  Macrophages release prostaglandins, thromboxane
and platelet-activating factor(PAF).
 PAF sustain bronchial hyperactivity
and causes capillaries to leak plasma that leads to
mucosal edema
 PAF also facilitates the accumulation of eosinophil's
within airways

13.  Eosinophils release various inflammatory mediators such as leukotriene
C4, and PAF, which results in epithelial damage and thick mucus
production that causes further deterioration in lung function.
 Hypertrophy and hyperplasia of bronchial smooth muscle occur by
these cell-derived mediators.
 Mucus gland hypertrophy leading to excessive mucus production and
airway plugging, airway oedema, acute bronchoconstriction and impaired
mucocilliary clearance.

14. Pathophysiology

16. Asthma can present in a number of ways. It may be manifest as a
persistent cough but commonly described as
 Recurrent episodes of difficulty in breathing (dyspnea) associated with
wheezing(a high-pitched noise due to turbulent airflow through a narrowed
airway.)

17. A series of routine tests has been developed to assess asthma such as
1. Forced expiratory volume(FEV)
This a most useful test for abnormalities in airway function. This is measured
by means of lung function assessment apparatus such as a spirometer. The
patient inhales as deeply as possible and then exhales forcefully and
completely into a mouthpiece connected to a spirometer.
The FEV1 is a measure of the FEV in the first second of exhalation.

18. I. Forced vital capacity(FVC) can also be measured, which is
an assessment of the maximum volume of air exhaled with
maximum effort after maximum inspiration.
II. FEV1 is usually expressed as a percentage of the total
volume of air exhaled, reported as the FEV1/FVC ratio.
III. Tidal volume is the volume of air inspired or expired during
normal breathing.
IV. Residual volume (RV) is the volume of air left in lungs after
maximum expiration.
V. Total lung capacity = VC + RV
Normal individual can exhale at least 70% of their lung capacity
in 1 sec.

19. I. Peak flow meter is a useful means of self-assessment for
the patient. it measures peak expiratory flow( PEF) rate.
II. Peak expiratory flow rate ,the maximum flow rate that can
be forced during expiration. It can be used to assess the
improvement or deterioration in the disease as well as the
effectiveness of treatment.
A healthy average young adult
male typically has a PER of
550 to 700L/minute

20.  These lung function test are used to demonstrate the
presence of air flow obstruction.
 Other test include
• Skin pricking test for IgE testing for specific allergens
• X-Rays
• Eosinophilic airway inflammation can be determined by
using sputum differential count
Chest X-Rays

21. The aim of asthma management is to have complete
control and have no exacerbations of disease
 BTS defines asthma control as
• No daytime symptoms
• No night time wakening
• No requirement of rescue medicines
• No asthma attack
• No limitation on activity
• Normal lung function tests FEV1 >80%
• Minimal adverse effect from medications

22. Persistent asthma
Components
of severity
Intermittent Mild Moderate Severe
Impairments Symptoms ≤2
days/weeks
>2
days/week
but not daily
Daily Throughout
the day
Nighttime
awakenings
≤2x/weeks 3-4x/month >1x/week
but not
nightly
Often
7x/week
SABA use for
symptom
control
≤2
days/weeks
>2
days/week
but not daily
Daily Several times
per day

23. Persistent asthma
Components
of severity
Intermittent Mild Moderate Severe
Interference
with normal
activity
None Minor
limitation
Some
limitation
Extremely
limited
Normal
FEV1/FVC
8-19yrs, 85%
20-39yrs, 80%
40-59yrs, 75%
60-80yrs, 70%
Lung function • Normal
FEV1
between
exacerbatio
n
• FEV1
>80%
predicte
d
• FEV1/FV
C normal
• FEV1
≥80%
predicte
d
• FEV1/FV
C normal
• FEV1
>60%
predicted
• FEV1/FVC
reduced
5%
• FEV1
<60%
predicted
• FEV1/FVC
reduced
>5%

24. Persistent asthma
Component of
severity
Intermittent Mild Moderate Sever
Risk Exacerbations
requiring oral
systemic
corticosteroids
0-1 year ≥2 in 1
year
Consider severity and interval since last
exacerbation. Severity and frequency may fluctuate
over time for patients. Relative annual risk of
exacerbations may be related to FEV1.

25. Persistent asthma
Intermittent Mild Moderate Sever
Level of
treatment
required to
maintain
control
Step-1 Step-2 Step 3 or 4 Step 5 or 6

26. Reliever medications
 Inhaled Short acting beta adrenoceptor agonist
(Salbutamol 200µcg)
 Inhaled anti-cholinergic agent (Ipratropium slower
onset of action)
 Long acting beta adrenoceptor agonist
 Oral bronchodilators (Theophylline)

27. Preventive medication
 Anti-inflammatory agent (Corticosteroids ;
Beclomethasone or Budesonide 400µcg/day)
 Leukotriene receptor antagonist (Montelukast,
Zafirlukast)
 IgE monoclonal antibodies (Omalizumab)
 Oral corticosteroid

28. Step2: Regular preventer therapy
Step1: Mild intermittent asthma
Inhaled short acting beta 2 agonists as required
Add inhaled steroid 200-800µcg/day
400µcg is an appropriate starting dose for many patients
Start a dose of inhaled steroid appropriate to severity of
disease

29. Step 5: Continues or frequent use of oral
steroids
• Use daily steroid tablet in lowest dose providing adequate control
• Maintain high dose inhaled steroids at 2000 µcg/day
• Consider other treatment to minimize the use of steroid tablet
• Refer patient for specialist care.
Step 4: Persistent poor control
• Consider trials of increasing inhaled steroids upto 2000 µcg/day
• Addition of fourth drug leukotriene receptor antagonist, SR
theophylline
Step 3: Add on therapy
Add inhaled beta 2 agonists (LABA)
Assess control of asthma
• Good response to LABA
• Benefit from LABA but control still inadequate-continue LABA and
increase inhaled steroid dose to 800µcg/day
• No response to LABA- stop LABA and increase inhaled steroid to
800µcg/day. If control still inadequate institute trial of other therapy
e.g. leukotriene receptor antagonists or SR theophylline

34. Drugs ADRs
Beta 2 agonists High doses: hypokalemia,
aggravation of angina
Inhaled corticosteroids Oral candidiasis, adrenal
suppression
Oral corticosteroids Mineralocorticoid effects include:
potassium loss, muscles
weakness, hypertension, sodium
and water retention.
Ipratropium Dry mouth
Nedocromil sodium Nausea, coughing, throat
irritation, headache
Theophylline Hyperglycemia, hypotension,
cardiac arrhythmia
Leukotriene receptor antagonist Abdominal pain, upper
respiratory tract infections

35.  The choice of suitable inhalation devices is vital in
asthma.
 Incorrect use of inhalers will lead to sub-optimal
treatment.

36.  Metered dose aerosol inhaler
 Dry powder inhalers
 Nebulisers (nebuliser produces an aerosol by
blowing air or oxygen through a solution to
produce droplet of 5µm or less in size)

37.  It usually contains a solution or suspension of
active drug, with typical particle size of 2-5µm in a
liquefied propellant.
 Operation of device releases a metered dose of
drug with droplet size of 35-45µm.
 This increase in droplet size is due to propellant
which evaporates when expelled from inhaler

38.  MDIs have the advantage of being multidose, small
and widely available for most drugs used in
asthma.
 Corticosteroids administered by MDIs causes oral
candidiasis so the patient is advised to gargle with
water after using inhalation and to expel the water
from mouth afterwards

42.  Corticosteroids and long-acting beta agonists
Some inhaled asthma medication combinations contain
both a corticosteroid and a bronchodilator:
• Fluticasone and Salmeterol (Advair Diskus)
• Budesonide and Formoterol (Symbicort)
• Mometasone and Formoterol (Dulera)
• Fluticasone and Vilanterol (Breo)
• Formeterol and Beclomethasone (Foster)

43.  Long-acting beta agonists (LABAs)
The most commonly used LABA for asthma is salmeterol
(Serevent).
 Quick relief drugs
Albuterol (ProAir HFA, Ventolin HFA, others)
Levalbuterol (Xopenex HFA)

44.  Clinical pharmacy and therapeutics Rogger
Walker 5th edition
 Applied therapeutics 9th edition (Marry Anne
Koda-Kimble)