2. Definition
a syndrome characterized by airflow
obstruction that varies markedly
relieved spontaneously or with Bronchodilator
± Corticosteroids
Chronic inflammatory disease of airways
↑ responsiveness of tracheobronchial tree
Physiologic manifestation: Air Way narrowing
which is usually reversible
Clinical manifestations: a triad of paroxysms
of cough, dyspnea and wheezing
3. Disease Pattern
Episodic --- acute exacerbations
interspersed with symptom free periods
Chronic --- daily Airway obstruction which
may be mild, moderate or severe ±
superimposed acute exacerbations
Life-threatening--- slow-onset or fast-
onset (fatal within 2 hours)
4. Prevalence
All ages, predominantly early life with peak
age of 3 years
Adults: ~10–12% population
Children: 15% population
50% dx <10y,85% dx <40y, 15% dx > 40y
2:1 male/female preponderance in
childhood ; equalize in adults
Asthma is both common and frequently
complicated by the effects of smoking on
the lungs
5. Etiology
Allergic/atopic/early onset asthma---
rhinitis,
urticaria, eczema, (+)skin tests, ↑IgE,(+)
response to provocation tests with
aeroallergens.
Idiosyncratic/non-atopic/intrinsic
asthma/late onset asthma--- no allergic
diseases,(-)skin tests, normal IgE,
symptoms when upper resp infection, sx
lasting days or months and usually have
15. Triggers of acute asthmatic
episodes
Allergens - pollen
Pharmacologic
stimuli such as
aspirin, NSAIDS, β-
blockers,
preservatives,col
agent
Environment
pollutionozone,SO2,
NO2
Occupational- metal
•Infection- resp viruses
•Exercise –cold dry air
→thermally-induced
hyperemia and
microvascular
engorgement
•Emotional stress
16. DIAGNOSIS : CLINICAL
Episodic asthma: Paroxysms of wheeze, dyspnoea
and cough, asymptomatic between attacks.
Acute severe asthma: Upright position, use
accessory resp muscles, can’t complete
sentences in one breath, tachypnea > 30/min,
tachycardia > 110/min, PEF < 50% of pred or
best, pulsus paradoxus, chest hyperresonant,
prolonged expiration, breath sounds
decreased, inspiratory and expiratory rhonchi.
17. Cont..
Life-threatening features: PEF < 33% of pred
or best, silent chest, cyanosis, bradycardia,
hypotension, feeble respiratory effort,
exhaustion, confusion, coma, PaO2 < 60,
PCO2 normal or increased, acidosis (low pH
or high [H+]).
Chronic asthma: Dyspnea on exertion,
wheeze, chest tightness and cough on daily
basis, usually at night and early morning;
intercurrent acute severe asthma
(exacerbations) and productive cough
(mucoid sputum), recurrent respiratory
18. DIAGNOSIS : PHYSIOLOGIC
Demonstration of variable airflow obstruction with
reversibility by means of FEV1 and PEF
measurement (spirometer and peak flow meter).
1. FEV1 < 80% of pred – PEF < 80% of pred.
2. Reversibility: A good bronchodilator response is a
12% or 200ml improvement in FEV1 15 min after
inhalation of 200ug salbutamol (2 puffs).
3. Diurnal peak flow variation: Normal variation:
Morning PEF 15% lower than evening PEF. With
asthma this variation is > 15% (morning dipping).
19. Cont..
4. Provocation studies:AHR
(a) Exercise: A 15% drop in FEV1 post
exercise indicates exercise induced asthma.
(b) Metacholine challenge: A 20% reduction in
FEV1 at Metacholine concentrations <
8mg/ml indicates bronchial hyperreactivity.
This is expressed as a PC20 value of eg 0.5mg/ml
(= a 20% reduction in FEV1 at 0.5mg/ml
Metacholine).
20. DIAGNOSIS :IMMUNOLOGIC
Skin prick wheal and flare response.
IgE.
Eosinophil cationic protein (ECP).
Peripheral blood and sputum eosinophilia.
21. DIAGNOSIS : RADIOLOGY
Chest XR may be normal between
attacks.
With attacks hyperinflation may be
found.
In complicated asthma segmental
lobar collapse (mucous plugs) and
pneumothorax can occur.
23. Risk factors for a fatal asthma
attack
Previous severe exacerbation (eg,
intubation or ICU admission)
Two or more hospitalizations for asthma in
the past year
Three or more emergency department
visits for asthma in the past year
Hospitalization or emergency department
visit for asthma in the past month
24. Risk factors for a fatal asthma
attack…
Use of more than two canisters of
short-acting beta agonist per month
Difficulty perceiving asthma symptoms
or severity of exacerbations
Low socioeconomic status, inner city
residence, illicit drug use, major
psychosocial problems
Comorbidities, such as cardiovascular,
chronic lung, or psychiatric disease
25. Criteria for Admission or
Discharge
The severity of the attack and response
to initial emergency room therapy
Risk factors for asthma mortality
26. Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms Nocturnal
Symptoms
FEV1 or PEF
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Mild
Intermittent
Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day
< 1 time a week
Asymptomatic and
normal PEF
between attacks
Frequent
> 1 time week
> 2 times a month
< 2 times a month
<60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
>80% predicted
Variability 20 - 30%
>80% predicted
Variability < 20%
The presence of one feature of severity is
sufficient to place patient in that category.
28. Cont..
Acute severe asthma:
1. Immediate Rx: O2 40-60% via mask or
cannula + β2 agonist (salbutamol 5mg) via
nebulizer + Prednisone tab 30-60mg and/or
hydrocortisone 200mg IV.
With lifethreatening features add 0.5mg
ipratropium to nebulized β2 agonist +
Aminophyllin 250mg IV over 20 min or
salbutamol 250ug over 10 min.
2. Subsequent Rx: Nebulized β2 agonist 6
hourly + Prednisone 30-60mg daily or
hydrocortisone 200mg 6 hourly IV + 40-60%
29. Cont..
No improvement after 15-30 min:
Nebulized β2 agonist every 15-30 min +
Ipratropium.
Still no improvement: Aminophyllin
infusion or alternatively salbutamol
infusion.
Monitor Rx: Aminophyllin blood levels +
PEF after 15-30 min + oxymetry (maintain
SaO2 > 90) + repeat blood gases after 2
hrs if initial PaO2 < 60, PaCO2 normal or
raised and patient deteriorates.
31. Discharge medications and
planning
Short-acting β2-agonist
Prednisone 30-60 mg daily x 5-14 days (no
taper needed for patients not previously on
steroids)
Inhaled corticosteroids at 500-1000 ug/day of
fluticasone or equivalent (Combination
inhaler)
Education
Proper technique in the use of inhalers
Roles of bronchodilators versus anti-
inflammatory agents
Written action plan
32. Mortality
Deaths from asthma are uncommon
Risks for death:-
poorly controlled disease with frequent
use of bronchodilator inhalers
lack of corticosteroid therapy
previous admissions to the hospital with
near-fatal asthma
34. COPD
Definition - a disease state characterized by
airflow limitation that is not fully reversible
COPD includes
Emphysema - an anatomically defined
condition characterized by destruction and
enlargement of the lung alveoli
Chronic bronchitis - a clinically defined
condition with chronic cough and phlegm
Small airways disease - a condition in which
small bronchioles are narrowed
35. COPD is present only if chronic airflow
obstruction occurs
chronic bronchitis without chronic airflow
obstruction is not included within COPD .
EPIDEIMOLOGY
fourth leading cause of death in US
affects >16 million persons in US
GOLD estimates suggest that COPD will
rise from the sixth to the third most
common cause of death worldwide by
2020.
37. Natural History
.The effects of cigarette smoking on
pulmonary function appear to depend on
The intensity of smoking exposure
Timing of smoking exposure during
growth
The baseline lung function of the
individual
.Genetic factors likely contribute to the
level of pulmonary function achieved
during growth and to the rate of decline
in response to smoking and potentially
40. Pathophysiology
Airflow Obstruction
o Persistent reduction in forced expiratory flow
rates .
o reduced FEV1
o reduced ratio of FEV1/FVC
Hyperinflation
o Increases in the residual volume and the
residual volume/total lung capacity ratio
Gas Exchange
o Non uniform distribution of ventilation
o Ventilation-perfusion mismatching
41. Clinical Presentation
History
Risk factors
cough, sputum production, and exertional
dyspnea
symptoms for months or years before seeking
medical attention
Activities involving significant arm work,
particularly at or above shoulder level, are
particularly difficult for patients with COPD
activities that allow the patient to brace the arms
and use accessory muscles of respiration are
better tolerated
44. Physical Findings
Early stages of COPD
Normal physical examination
Current smokers - signs of active
smoking ( an odor of smoke or nicotine
staining of fingernails )
45. severe disease
prolonged expiratory phase and expiratory
wheezing
signs of hyperinflation ( a barrel chest and
enlarged lung volumes with poor
diaphragmatic excursion)
use of accessory muscles of respiration,
sitting in the characteristic "tripod"
46. Advanced disease
systemic wasting - significant weight loss,
bitemporal wasting, and diffuse loss of
subcutaneous adipose tissue
paradoxical inward movement of the rib
cage with inspiration (Hoover's sign)
Signs of overt right heart failure
Clubbing of the digits is not a sign of COPD
47. Laboratory Findings
Arterial blood gases and oximetry
Hematocrit – Secondary polycythemia
Pulmonary function testing
-reduction in FEV1 and FEV1/FVC
-lung volumes may increase, resulting in
an increase in total lung capacity, functional
residual capacity, and residual volume
54. Exacerbations of COPD
Bronchodilators
Antibiotics
Glucocorticoids
Oxygen
Mechanical Ventilatory Support
55. Mild to moderate exacerbations
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Chlamydia pneumoniae
Mycoplasma pneumoniae
Viruses
Severe exacerbations
Pseudomonas species
Other gram-negative enteric bacilli
Common Infectious Causes of COPD
Exacerbations
56. Mild to moderate exacerbations
First-line antibiotics
Doxycycline (Vibramycin), 100 mg twice daily
Trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS), one
tablet twice daily
Amoxicillin-clavulanate potassium (Augmentin), one 500 mg/125
mg tablet three times daily or one 875 mg/125 mg tablet twice daily
Alternative antibiotics
Macrolides
Clarithromycin (Biaxin), 500 mg twice daily
Azithromycin (Zithromax), 500 mg initially, then 250 mg daily
Fluoroquinolones
Levofloxacin (Levaquin), 500 mg daily
Gatifloxacin (Tequin), 400 mg daily
Moxifloxacin (Avelox), 400 mg daily
Antibiotic Choices for COPD
Exacerbations
57. Moderate to severe exacerbations: Recommend IV
antibiotics
Cephalosporins
Ceftriaxone (Rocephin), 1 to 2 g IV daily
Cefotaxime (Claforan), 1 g IV every 8 to 12 hours
Ceftazidime (Fortaz), 1 to 2 g IV every 8 to 12 hours
Antipseudomonal penicillins
Piperacillin-tazobactam (Zosyn), 3.375 g IV every 6 hours
Ticarcillin-clavulanate potassium (Timentin), 3.1 g IV every 4 to 6
hours
Fluoroquinolones
Levofloxacin, 500 mg IV daily
Gatifloxacin, 400 mg IV daily
Aminoglycoside
Tobramycin (Tobrex), 1 mg per kg IV every 8 to 12 hours, or 5 mg
per kg IV daily
Antibiotic Choices for COPD
Exacerbations
58. For severe exacerbations of COPD
requiring inpatient therapy,
methylprednisolone sodium succinate
(Solu-Medrol) is commonly used initially.
Dosage: Commonly 60mg or 125mg every
six to twelve hours depending on severity of
exacerbations
After two to three days of intravenous
therapy, the patient can be switched to orally
administered prednisone in a starting
dosage of 60 mg daily for a total of two
Corticosteroids in COPD
Exacerbations
