This presentation is all about asthma. Not a minor detail is missing. Thank me later!

1. Subject: Clinical Pharmacy & Therapeutics I
Topic: Asthma
Submitted to: Sir Qamar-uz-Zaman
Submitted by: Sahrish Jabbar
Roll no.: 02
M.Phil. Pharmacy Practice
(2nd semester, Fall 2022-2024)

3. Components of respiratory pathway
• Nose
• Mouth
• Throat (pharynx)
• Voice box (Larynx)
• Wind pipe (trachea)
• Bronchi (Left & Right)
• Lungs (Left & Right)
• Bronchioles
• Air sacs (Alveoli)

4. Normal physiology of respiratory pathway

5. Asthma
• Asthma means “labored breathing”
• It is a broad term used to refer to a disorder of the
respiratory system that leads to episodic difficulty
in breathing
• This is an obstructive lung disease
• Obstruction is often reversible either spontaneously
or with treatment

6. 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 variable airflow
obstruction and an increase in airway response to a
variety of stimuli

7. Epidemiology
• Asthma affected an estimated 262 million people in
2019 and caused 455 000 deaths (WHO)
• Fifteen million children and 7.5 million adults are
suffering from asthma in Pakistan (Khan, M.A.
Monthly and seasonal prevalence of asthma)

9. Events
Two main causes of asthma symptoms are:
I. Airway hyper-responsiveness
II. Bronchoconstriction
₋ Hyper-responsiveness is an increased tendency to
react to stimuli or trigger
₋ Bronchoconstriction is a narrowing of the airways

10. Changes in Airways in Asthma

11. Triggers for an asthma attack

12. Types of asthma
• Seasonal asthma (Pollen)
• Occupational asthma (industrial)
• Drug induced asthma (beta blockers, NSAIDs)
• Extrinsic asthma (Allergen)
• Intrinsic asthma ((Non-Allergenic)

13. Symptoms
• Difficult breathing
• Wheezing
• Chest tightness
• Coughing

14. Pathophysiology

15. • 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
• Bronchoconstriction and also causes mucus gland
to hyperactive and start producing mucous
• Various chemotactic agents that attract eosinophils
and neutrophils.

16. • 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

17. • Eosinophil release various inflammatory mediators
which results in epithelial damage and thick mucus
production
• Hypertrophy and hyperplasia of bronchial smooth
muscle occur

18. Clinical manifestations
Asthma may manifest as:
• Persistent cough (may or may not be productive)
• Recurrent episodes of dyspnea
• Wheezing (prolonged expiration)
• Chest tightness
• Difficulty speaking

19. Diagnosis or investigations
I. Pulmonary Function Test (Gold Standard)
Used for symptomatic patient
Forced expiratory volume(FEV)
• Most useful test for abnormalities in airway
function
• Measured by means of lung function assessment
apparatus such as a spirometer
• Patient inhales as deeply as possible and then
exhales forcefully and completely into a
mouthpiece connected to a spirometer

20. Forced vital capacity(FVC)
• Maximum volume of air exhaled with maximum
effort after maximum inspiration
• FEV1 is a measure of the FEV in the first second of
exhalation.
• FEV1 is usually expressed as a percentage of the
total volume of air exhaled, reported as the
FEV1/FVC ratio
• Normal individual can exhale at least 70% of their
lung capacity in 1 sec

22. II. Methacholine Challenge Test
• Asymptomatic patient
• PFTs performed
• Slightly reduced FVC, very low FEV1, and
FEV1/FVC is less than 75%
• Administer muscarinic agonist, Methacholine
• Bronchoconstriction
• Again perform PFTs
• If the patient is asthmatic, FEV1 will drop 20% or
more than original

23. III.CBC
Eosniophils
IV. Serology
IgE
V. Chest X-ray
Hyperinflation
VI. ABGs
PaCO2 due to hyperventilation

24. VI. Peak flow meter
• Useful means of self-assessment for the patient
• Measures peak expiratory flow( PEF) rate.
Peak expiratory flow rate
• Maximum flow rate that can be forced during
expiration
• 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

27. Treatment goals
The aim of asthma management is to have complete
control and have no exacerbations of disease
• 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

28. Disease
severity
Daytime
symptoms
Nighttime
awakenings
Pulmonary
function
FEV1
Interference
with normal
activity
Treatment
Intermittent ≤ 2 / week < 3x / month Normal
FEV1 > 80%
None SABA
Mild > 2 days /
week but not
daily
3-4x / month Normal
FEV1 > 80%
Minor
limitation
SABA + ICS at
low doses
Moderate Daily
7x / week
1x / week FEV1 60-80% Moderate
limitation
SABA + med.
Dose ICS
OR
Low dose ICS
+ LABA
Severe Everyday
throughout
the day
Every night
throughout
the night
FEV1 < 60% Extremely
limited
SABA + Med
dose ICS +
LABA
OR
SABA + High
dose ICS +
LABA
OR
These three +

29. Drugs used in Asthma
I. Reliever Medications
II. Preventive Medications
I. Reliever Medications
• Inhaled SABA
• Inhaled Anti-cholinergic
• LABA
• Oral Bronchodilator

30. II. Preventive Medications
• Inhaled Corticosteroids
• Leukotriene Receptor Antagonist
• IgE Monoclonal Antibodies
• Oral Corticosteroids

31. ADRs of Anti-Asthmatic Agents
Drugs ADRs
SABA Tachyarrhythmia, tremors, dizziness, C/I in
narrow angle glaucoma
LABA Never in acute exacerbations, aggravation of
angina
ICS Oral candidiasis
Oral Corticosteroids Exaggeration of normal physiologic effects of
steroids, muscle weakness, Na & water
retention
Ipratropium Dry mouth
Leukotriene Receptor antagonist Abdominal pain, URI

32. Asthma Exacerbations
Associated with:
• Tachypnea (Hyperventilation)
• Tachycardia
• Diaphoresis
• Fatigue
• Accessory Muscle Use

33. Acute Exacerbation Symptoms:
• Silent Chest (Main symptom)
• Absent Wheezes
• Cyanosis
• Bradycardia
• SPO2 < 92%
• When ABG performed, PaCO2 found to be normal
or increased which indicates respiratory muscle
fatigue heading towards Respiratory Failure

34. Treatment of Acute Exacerbation of Asthma
• Immediate management includes:
• Oxygen to maintain SPO2 94-98%
• Salbutamol 5mg + Ipratropium 0.5 mg via oxygen
driven nebulizer
• Prednisolone 40-50 mg orally or Hydrocortisone IV
100 mg
• Mg-Sulphate IV 1.2-2 g over 20 min.
 If the patient is comatose, PaCO2 > 45 (raised than
normal; Respiratory Acidosis), PaO2 < 60, he/she
must be admitted to ICU and ETT performed

35. Inhalation Devices
• The choice of suitable inhalation devices is vital in
asthma
• Incorrect use of inhalers will lead to sub-optimal
treatment
• No demonstrable differences in efficacy between
the various devices available

36. Factors considered while selecting appropriate device:
• Patient’s age
• Severity of disease
• Personal preference
Types of Inhalers
i. Metered Dose Inhalers
ii. Combination Inhalers
iii. Dry Powder Inhalers
iv. Nebulizers

37. Metered Dose Inhalers (MDI)
• Most widely prescribed inhalation device
• Contains a soln. or susp. of active drug with a
typical particle size of 2-5µm, in a liquefied
propellant
• Operation of the device releases a metered dose of
35-45µm
Advantages of MDI
• Multi-dose, small, widely available for most
asthmatic drugs

38. • Major disadvantage is difficulty in coordinating the
beginning of inspiration with the actuation of
inhaler
• MDIs only deliver 10% drug to airways and 80%
deposited in the oropharynx
• Corticosteroids administered by MDIs cause
candidiasis

39. Technique for using Metered Dose Inhalers
• Remove the cap from mouthpiece and shake
vigorously
• Patient should breath out gently not fully
• The tongue should be placed on the floor of the
mouth and the inhaler placed between the lips
which are then closed around the mouth piece
• The patient now start to breathe in slowly and
deeply by mouth

40. • Canister is pressed to release the dose while
breathing, and hold the breath for 10s allow drug to
reach lungs
• If second dose is required 30-60s should elapse
before repeating the procedure to allow refill

42. Combination Inhalers
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)

44. Dry Powder Inhalers
• Device that delivers medication to the lungs in the
form of a dry powder
• Alternative to the aerosol-based MDI
• Measured dose of powder to be ready for the patient
to take
• Available as both single dose and multi dose
• Multiple dose DPIs are preferred as reloading for
each dose can be avoided

45. • DPIs pierce or break the gelatin capsule to release
the contents
• Must be regularly cleaned to avoid clogging of
powder

46. Nebulizers
A nebulizer is a small machine that turns liquid
medicine into a mist that can be easily inhaled
Types of Nebulizers
• Most nebulizers work by using air compressors
• Ultrasonic nebulizer, uses sound vibrations.

47. • Nebulizers come in three main types:
a) Jet - Compressed air turns the medicine into a mist
b) Mesh - Medicine is passed through a tiny mesh to
create a fine mist
c) Ultrasonic - High frequency vibrations turn
medicine into a mist
• Nebulizers require little coordination from the
patient
• Doses are higher than those used in MDI
• Nebulizers are useful for those who are unable to
use conventional inhalers e.g. children under 2
years

48. • Most of the SABA and ICS as well as Ipratropium
are available for nebulization

49. References
• Current Medical diagnosis and Treatment 2014 –
Fifty fourth edition
• GINA guidelines 2020
• Clinical pharmacy and therapeutics Roger Walker
5th edition
• Applied therapeutics 9th edition (Marry Anne Koda-
Kimble)
• basicmedicalkey.com/asthma