Bronchial asthma is a chronic inflammatory disease of the airways characterized by wheezing, coughing, chest tightness, and difficulty breathing. Symptoms are caused by bronchial hypersensitivity and reversible airflow obstruction. The document discusses the definition, pathophysiology, diagnosis, classification of severity, goals of treatment, and medications used for long-term control and quick relief of symptoms. Treatment involves a stepwise approach using inhaled corticosteroids and other controllers to prevent symptoms and exacerbations.

1. What is the disease?

2. Bronchial Asthma
Shi Ruiming
史瑞明

3. Review sheet
1. Atopy
2. FEV1
3. PEFR
4. PEF variation
5. Bronchial hypersensitivity

4. A hereditary disorder marked by the tendency to
develop immediate allergic reactions to substances
such as pollen, food, dander, and insect venoms
and manifested by hay fever, asthma, or similar
allergic conditions.

5. Review sheet
1. Atopy
2. FEV1 : forced expiratory volume in 1 second
3. PEFR
4. PEF variation
5. Bronchial hypersensitivity

7. Review sheet
1. Atopy
2. FEV1
3. PEFR: peak expiratory flow rate
4. PEF variation
5. Bronchial hypersensitivity

9. Normal Asthma
Morning peak flow
Evening peak flow
PEFR
(%Predicted)
100%
50%
100%
50%

10. Review sheet
1. Atopy
2. FEV1
3. PEFR
4. PEF variation
5. Bronchial hypersensitivity

11. Normal Asthma
Morning peak flow
Evening peak flow
PEFR
(%Predicted)
100%
50%
100%
50%

12. Review sheet
1. Atopy
2. FEV1
3. PEFR
4. PEF variation
5. Bronchial hypersensitivity

13. Bronchial hyperresponsiveness (BHR)
is defined as an increase in sensitivity
to a wide variety of airway narrowing
stimuli. In asthma, in particular, this
hypersensitivity is accompanied by
excessive degrees of airway narrowing.

14.  Asthma is one of the most common
chronic diseases worldwide.
 The prevalence is increasing, especially
among children.
 The prevalence of asthma symptoms in
children varies from 0 to 30 percent
 In different populations with the highest
prevalence occurring in Australia, New
Zealand and England.

16. 0 5 10 15 20 25 30 35
1992
1982
1989
1975
1992
1982
1994
1989
1992
1982
1992
1982
1991
1979
1989
1966
Finland
(Haahtela et al)
Sweden
(Aberg et al)
Japan
(Nakagomi et al)
Scotland
(Rona et al)
UK
(Omran et al)
USA
(NHIS)
New Zealand
(Shaw et al)
Australia
(Peat et al)
{
Prevalence (%)
{
{
{
{
{
{
{
Increasing Prevalence of Asthma in
Children/Adolescents

17. 1990 2000
sample
patients
Patient>3y
Patient<3y
morbidity
male: female
Age of occur
Highest city
Lowest city
399,193
3625
2691
934
0.91
1.5:1
<6y(90%)
重庆(2.6%)
拉萨(0.09%)
287,329
4,301
3540
761
1.50(increase 0.7time)
1.65:1
<6y(90%)
重庆, 上海(3.34%)
拉萨(0.52%)
China：1990 and 2000 0-14y epidemic investigation

18. Definition
 Chronic inflammatory disorder of the
airways
 Characterized by wheezing, coughing,
chest tightness, difficult breathing or
breathlessness
 Bronchial hypersensitivity to stimuli
 Airflow obstruction is reversible, either
spontaneously or with treatment

19. The “Tip” of the Iceberg
Airway
inflammation
Airflow
obstruction
Bronchial
hyperresponsiveness
TITANIC
Symptoms
Asthma

20. Etiology
 The etiology or cause of asthma is not well
understood at this time
 What is known:
 Asthma occurs in families
 Is associated with atopy (atopic dermatitis)
 Associated with allergen and chemical
exposure
 Increased risk with small birth size
 Diet?

21. Histopathology
 Denudation of the airway epithelium
(change in the lining of the airway)
 Edema (swelling)
 Mast cell activation (cells involved in
allergic mediation)
 Presence of other inflammatory cells

26. Asthma Triggers
 Allergen exposure
 Respiratory infections
 Vigorous exercise
 Cold air
 Dust
 Strong emotion
(laughing, crying)
 Air pollution
 Cigarette smoking
 Drugs
 Pets

28. Asthma: Factors That Exacerbate
(Intensify ) Symptoms
 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food additives, drugs

29. Pathogenesis

30. Eosinophils
Mediators
Histamine
Leukotrienes
Prostaglandins
Mast cell tryptase
Eosinophil cationic protein
Cytokines (IL-4, IL-5)
Mast cells
T lymphocytes
many
other cells
Inflammatory Cell-Derived Mediators
Asthma

31.  The Early and Late Asthmatic Response
following Allergen Challenge

33. symptoms and signs
 History of any of the following:
• Cough, worse particularly at night.
• Recurrent wheeze.
• Recurrent difficulty breathing.
• Recurrent chest tightness.
 Wheezing–high-pitched whistling sounds when
breathing out–especially in children. (A normal
chest examination does not exclude asthma.)
 Symptoms occur or worsen at night, awakening
the patient.
 Reversible and variable airflow limitation

34. Asthma Diagnosis
 History and patterns of symptoms
 Physical examination
 Measurements of lung function
 Measurements of allergic status to
identify risk factors

35. Skin test

37. Asthma: FEV1 Decreased

38. Normal Asthma
Morning peak flow
Evening peak flow
PEFR
(%Predicted)
100%
50%
100%
50%
PEFR recorded twice-daily over 2 weeks

39. Asthma severity
3
4
2
1
Severe Persistent
Moderate Persistent
Mild Persistent
Intermittent
Severity is classified before therapy begins
• Symptoms
• Activity levels
• Exacerbations
• FEV1/PEFR
• PEFR variability
Classified by:
Severity is classified before therapy begins
Asthma

40. 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
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.

42. A six-part program to manage and control
asthma
 Part 1. Educate children/families to develop a
partnership in asthma care.
 Part 2. Assess and monitor asthma severity.
 Part 3. Avoid exposure to risk factors.
 Part 4. Establish individual medication plans
for long-term management in infants and
preschool children, school children, and
adolescents with asthma.
 Part 5. Establish individual plans to manage
asthma attacks.
 Part 6. Provide regular follow up care.

43. Goals of Therapy
 Prevent chronic symptoms
 Maintain “normal” pulmonary function
 Prevent exacerbations
 Meet patient’s and families’ expectations of
and satisfaction with asthma care

44. Goals of Therapy
 Minimal (ideally no) need for quick relief
beta2-agonist therapy
 No emergency visits to doctors or hospitals
 Maintain normal activity levels, including
exercise
 Minimal or no adverse effects of medicine

45. Overview of Asthma Medications
 Long-term control
 Corticosteroids
 Cromolyn
/Nedocromil
 Long-acting beta2-
agonists
 Leukotriene
modifiers
 Quick relief
 Short-acting
inhaled beta2-
agonists
 Anticholinergics
 Systemic
corticosteroids

46. inhalation therapy

47. Stepwise Approach to Asthma Therapy
Controller:
 Daily inhaled
corticosteroid
Controller:
 Daily inhaled
corticosteroid
 Daily long-
acting inhaled
β2-agonist
Controller:
 Daily inhaled
corticosteroid
 Daily long –
acting inhaled
β2-agonist
 plus (if needed)
 When
asthma is
controlled,
reduce
therapy
 Monitor
Outcome: Asthma Control Outcome: Best
Possible Results
Controller:
None
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
Reliever: Rapid-acting inhaled β2-agonist prn

48. Recommended Asthma Medications
Step 1: Children
Severity Daily Controller
Medications
Other Options (in order
of cost)
Step 1:
Intermittent
 None  None

49. Recommended Asthma Medications
Step 2: Children
Severity Daily Controller
Medications
Other Options (in order
of cost)
Step 2:
Mild
Persistent
 Inhaled
glucocorticosteroid
(100 – 400 μg
budesonide or
equivalent)
 Sustained-release
theophylline, or
 Cromolyn, or
 Leukotriene modifier

50. Recommended Asthma Medications
Step 3: Children
Severity Daily Controller Medications Other Options (in order of cost)
Step 3:
Moderate
persistent
 Inhaled
glucocorticosteroid
( 400 – 800 μg budesonide
or equivalent)
 Inhaled glucocorticosteroid (< 800 μg
budesonide or equivalent) plus
sustained-release theophylline, or
 Inhaled glucocorticosteroid (< 800 μg
budesonide or equivalent) plus long-
acting inhaled β2- agonist, or
 Inhaled glucocorticosteroid at higher
doses (> 800 μg budesonide or
equivalent), or
 Inhaled glucocorticosteroid (< 800 μg
budesonide or equivalent) plus
leukotriene modifier

51. Recommended Asthma Medications
Step 4: Children
Severity Daily Controller Medications Other Options
Step 4
Severe
persistent
 Inhaled glucocorticosteroid
( > 800 μg budesonide or
equivalent)
 plus one or more of the following,
if needed:
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled β2- agonist
- Oral glucocorticosteroid

52. Step Down

53. Role of the Pharmacist
 1. Educate patients about asthma
medications.
 2. Instruct patients about the proper
techniques for inhaling medications.
 3. Monitor medication use and refill
intervals to help identify patients with
poorly controlled asthma.

54. Role of the Pharmacist
 4. Encourage patients purchasing OTC
asthma inhalers or tablets to seek medical
care.
 5. Help patients use peak flow meters
appropriately.
 6. Help patients discharged from the
hospital understand their asthma
management plan.

55. Major New Revisions
 Medications now classified as long-term control
and quick relief
 Continued emphasis that most effective control for
long-term control are those with anti-
inflammatory effect
 New medications available
 Long-acting inhaled beta-agonists
 Leukotriene modifiers
 Nedocromil

56. Major New Revisions (Continued)
 Address issues regarding safety of
medications
 Stepwise approach emphasizes initiating
therapy at a higher level and then stepping
down
 Recommendations on estimated clinical
comparability of inhaled corticosteroids

58. The End
Questions?

59. Medications of Interest: Serevet
(Salmeterol)
 Available in MDI and DPI
 Long acting bronchodilator for long term control
 Not to be used in place of anti-inflammatory
 Used with inhaled steroid in step 3
 May use one nightly dose for nocturnal symptoms
 Duration of bronchodilation 12 hours
 Not to be used for symptom relief or for
exacerbations

60. Medications of Interest: Flovent
Fluticasone
 Inhaled steroids are most effective anti-
inflammatory currently available.
 Twice daily dosing for improved
compliance.
 Multiple strengths available.
 As with all steroids it is important to rinse
mouth after use and spacers are helpful.

61. Summary
 Asthma is a significant cause of illness and
death in the United States
 Asthma is a chronic disease and requires
continuous surveillance
 Appropriate use of long term control
medications can improve quality of life for
people with asthma