Asthma is a chronic inflammatory disorder of the airways causing airflow obstruction and recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Chronic inflammatory airway disease associated with increased airway responsiveness and reversible airway obstruction. It can present at any age; majority of cases diagnosed in childhood Most of them become asymptomatic by adolescence Disease severity rarely progresses; patients with severe asthma have it at the onset. FACTORS EFFECTING ASTHMA: The inside lining of the airways becomes red and swollen (inflammation) Extra mucus (sticky fluid) may be produced The muscle around the airways tightens (bronchoconstriction) DIAGNOSIS: Pulse oximetry and ABG analysis Chest Xray Blood Test Peak Flow meter + Spirometry- PEFR + FEV1 decrease PEFR + FEV1 increase >15% after β agonist inhalation Skin Testing

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SUBMITED BY
P.DEVI GUNA SIREESHA
Y16MPH355
SUBMITED TO:
Dr. K. Phani Kumar PhD
D.Chandra Shekar Reddy(PhD)

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4.  Chronic inflammatory airway disease associated with
increased airway responsiveness and reversible airway
obstruction.
 It can present at any age; majority of cases diagnosed
in childhood
 Most of them become asymptomatic by adolescence
 Disease severity rarely progresses; patients with severe
asthma have it at the onset.
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 The inside lining of the airways becomes red and swollen
(inflammation)
 Extra mucus (sticky fluid) may be produced
 The muscle around the airways tightens
(bronchoconstriction)

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9. Pulse oximetry and ABG analysis
Chest Xray
Blood Test
Peak Flow meter + Spirometry-
PEFR + FEV1 decrease
 PEFR + FEV1 increase >15% after
β agonist inhalation
Skin Testing
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10. Anti inflammatory drugs
Bronchodilators
Anti inflammatory drugs
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12. Relievers
Controller
• b2 agonists
• Anticholinergics
• Methylxanthines
• Corticosteroids
• Mast cell stabilizers
• Anti Leukotriens
• Biological Agents
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13. Classified as:
 SABAs(short acting)- Salbutamol, Terbutaline,
Levalbuterol, Fenoterol, Pirbuterol, Metaproterenol
 LABAs(Long acting) - Salmeterol, Formoterol
 Ultra LABA: Indicaterol ( yet not approved for
asthma)
Beta-2 Agonists

14.  Mechanism:cause bronchial smooth muscle relaxation by
decreasing calcium, opening potassium channels, inhibiting
myosin light chain kinase (MLCK) and stimulating myosin light
chain phosphorylase(MLCP)
 Short acting drugs :Onset of action is 5 minutes,duration
of action (4-6 hrs) & hence are drug of choice for acute attack
 Long acting drugs:Duration of action (12 hrs)& hence at BD
doses used for prophylaxis
 Ultra long acting drugs : duration of action is 24 hrs & hence
used at OD doses for prophylaxis of asthma
 Side effects :Tremors are most common due to β2 receptor
stimulation in skeletal muscles
Other-palpitations, QT prolongation
Beta-2 Agonists

15. Name Oral Parentral Inhaled
Salbutamol 2- 4 mg 0.25-0.5mg,IM/SC 100-200g
Levalbuterol - - 0.63-1.25 mg
Terbutaline 5mg 0.25mg,SC 250 g
Metaproteronol - - 650 g
Pirbuterol - - 200 g
Salmeterol - - 50-100 g.
Formoterol - - 12-24g.
Bambuterol 10-20mg. - -
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16. Anticholinergics
M3 > M1
 Ipratropium
 Tiotropium
 Oxitropium

17.  These drugs mainly cause dilation of large airways
 Less effective than beta-2 agonists as they inhibit only the
cholinergic reflex component of bronchoconstriction
 These drugs are not approved by FDA but used off label in
patients not responding to or intolerant to β2 agonists
 Combined with β2-agonists in treating acute severe asthma
Anticholinergics

18.  Ipratropium : short acting (6 hrs) & hence can
be used for an acute attack of bronchial
asthma
 Oxitropium: Intermediate acting & can be
used in nocturnal asthma
 Tiotropium : longest acting(24 hrs) & used in
long term prophylaxis in combination with
corticosteroids
Anticholinergics Contd…

19.  Drugs include :
Theophylline, Aminophylline, Theobromine
 Mechanism :
 Act by inhibiting Phosphodiesterase which is involved
in breakdown of cAMP & by blockade of adenosine
receptors
 Inhibition of phosphodiesterase in lymphocytes gives
additional anti-inflammatory effect
Methylxanthines

20.  Theophylline can be used by oral route at a dose of 8
mg/kg BD for persistent asthma along with inhalational
corticosteroids
 Aminophylline can be used by I.V route with a loading
dose of 6mg/kg followed by 0.5 mg/kg/hr for
treatment of Acute attack of asthma
Methylxanthines Contd…
Theophylline has a low therapeutic index and hence
therapeutic monitoring is done to maintain plasma
concentration within range i.e 5-15 mg/L

21.  These are potent anti-inflammatory drugs & also
decrease bronchial hyperactivity & mucosal edema.
 Mechanism: Arachidonic acid (AA) is released
from the membrane phospholipids with the help of
enzyme phospholipase A2 that is inhibited by
corticosteroids. AA is converted to PG and TX by
cyclooxygenase and to LT with the help of enzyme
5-lipooxygenase (5 LOX). Thus, these mediators are
not generated when corticosteroid therapy is initiated
Corticosteroids

22.  Steroids are used if patient has to use SABA more than 2
times a week for symptomatic relief
 Systemic steroids have a lot of adverse effects,
therefore are reserved for resistant severe chronic
asthma and in status asthmaticus
 Hydrocortisone( 100 mg bolus) is I.V. Steroid of choice as
it is fastest acting systemic steroid
 Oral prednisolone can be used for persistent asthma
Corticosteroids

23.  Inhalational corticosteroids are drug of choice for
persistent asthma
Corticosteroids Contd..
 Beclomethasone dipropionate 200-400 g BD
 Flunisolide 25 g BD
 Budesonide 200-400 g BD
 Fluticasone propionate 100-250 g BD
 Ciclosenide 40 – 160 g OD

24.  Sodium cromoglycate and nedocromil prevent the
degranulation of mast cells by trigger
stimuli indicated only for prophylaxis of bronchial
asthma given by inhalational route.
 Ketotifen has antihistaminic action apart from mast
cell stabilizing property and is specially indicated for
patients with multiple disorders (atopic dermatitis,
perennial rhinitis, conjunctivitis etc.).
Mast cell stabilizers

25. Omalizumab is a monoclonal antibody against
IgE and is indicated to prevent the attack of
bronchial asthma in patients not responding to
combination of long acting β2 agonist and a
high dose of inhalational steroid. It is
administered by Subcutaneous route
Drug inhibiting IgE Action

26.  Asthma medications can be inhaled (breathed in) or taken
orally (swallowed).
Most people use inhaled asthma medication because:
 Medication goes directly to the lungs
 Inhalers need to be used correctly to ensure maximum
benefits are achieved.
This means that:
 Asthma improves more rapidly
 Better control is maintained
 Less medication is needed
 Fewer side effects are experienced
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27. Pharmacotherapy of bronchial asthma

28.  Acute asthmatic attack not responding to routine
treatment & β2 agonist, life threatening condition
 Precipitated by:
 Acute respiratory infection
 Abrupt cessation of steroid therapy
 Pharmacological stimuli/allergens
 Acute emotional stress

29.  Hydrocortisone Hemisuccinate 100mg iv stat 4-8 hourly
infusion (take 6 hours to act)
 Nebulized salbutamol (2.5-5mg) + Ipratropium Bromide
(0.5mg)
 High flow humidified O2
 Salbutamol/Terbutaline 0.4mg S.C/I.M
 Intubation and mechanical ventilation
 Antibiotics
 Saline + Sod. Bicarbonate

31.  Pretreatment before exercise-
Inhaled beta2-agonists- prevent EIB in more than 80
percent
 SABA use may be helpful for 2–3 hours
 LABAs can be protective up to 12 hours
 Leukotrine receptor antagonist can attenuate EIB in up to
50 percent of patients
 Cromolyn or nedocromil taken shortly before exercise is
an alternative

32.  Attempts made to improve lung function preoperatively
 Short course of oral systemic corticosteroids may be
required
 For patients who have received oral systemic
corticosteroids during the past 6 months and for pts on a
long-term high dose of ICS
 100 mg hydrocortisone every 8 hours i.v during the
surgical period & reduce dose rapidly within 24 hours after
surgery

33.  Asthma increases risk of preterm birth, IUGR and
perinatal mortality.
 NEVER WITHHOLD TREATMENT
 Monitoring of asthma status during prenatal visits
 Albuterol is the preferred SABA because it has an
excellent safety profile
 ICS are the preferred treatment for long-term control
medication
 Budesonide is the preferred ICS because more data are
available

35. Inhalational delivery systems
Dry Powder Inhalers
Metered Dose Inhaler Spacer
Nebuliser

36. METERED DOSE INHALER
1. Take off the cap.
Shake the inhaler
well.
2. Breathe out
though your
mouth.
3. Place the inhaler
between your lips. As
you start to breathe in,
press the top end of
the inhaler and keep
breathing in steadily
and deeply.
4. Remove the inhaler
from your mouth. Hold
your breath for 10
seconds or as long as you
find comfortable.
Breathe out.

37. The Spacer is a holding chamber which can be attached to
the Metered Dose Inhaler.
1. Assemble the
Spacer by pushing
the notch of one
half into the slot
of the other half.
2. After shaking the
inhaler well, fit it
into the Spacer.
3. Breathe out
through your
mouth. Then close
your lips around the
Spacer.
4. Press the top
end of the
inhaler. Then,
breathe in deeply
though your
mouth.
SPACER

38. Dry Powder Inhalers
1. Insert the
transparent end of
the Rotacap into the
raised square hole of
the rotahaler.
2. Hold the top of the
Rotahaler firmly with
one hand. Rotate the
base until the capsule
breaks.
3. Breathe out through
your mouth. Then,
placing the Rotahaler
between your lips (as
shown), breathe in
though your mouth as
deeply as possible.
4. Remove the Rotahaler
from your from your
mouth. Hold your breathe
for 10 seconds or as long as
you find comfortable.
Breathe out.

39. Attach the hose and mouthpiece to the
medicine cup
Place the mouthpiece in your mouth.
Breathe through your mouth until all the
medicine is used, about 10-15 minutes.
Wash the medicine cup and mouthpiece with
water, and air-dry until your next treatment
NEBULISERS
2 types: Jet nebulisers
Ultrasonic nebulisers

41. INDICATEROL:
 Inhaled once-daily β2 agonist
 Onset of action faster than salmeterol
 Duration of action ~ 24 hrs
 Has been approved only for COPD
 Clinical trials in asthma underway to test safety and
efficacy of once-daily combination of indacaterol
with mometasone

42.  Mapracorat: Selective glucocorticoid receptor agonist that
targets receptors for inflammation only & is devoid of
systemic side effects
 Abediterol: Ultra LABA under trial for bronchial asthma
prophylaxis
 Recently MgSo4 by I.V. and inhalational route has been
tried for acute severe asthma.
Recent advances Contd…

43. Pharmacotherapy of bronchial asthma

44. Pharmacotherapy of bronchial asthma

45. Pharmacotherapy of bronchial asthma

46.  Catheter introduced through a
bronchoscope
 It delivers thermal energy to the
airway wall to reduce excess
smooth muscle
 Increases symptom-free days,
improves PEFR and reduces the
use of reliever medicines.
 FDA approval obtained in 2010 for
treatment of severe asthma.

47.  Influenza causes significant morbidity and mortality
in the general population, and the risk can be reduced
by annual vaccination. Influenza contributes to some
acute asthma exacerbations, and patients with
moderate-severe asthma are advised to receive an
influenza vaccination every year
Vaccination

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49.  Patient awareness/education
 Efficacy of patient education and parental
awareness has also been shown to be effective in
individual studies from India
 Lifestyle Modifications: Regular balanced diet and
avoidance of obesity.
Short acting beta-2 agonists should be used prior to
anticipated exercise, in a patient with exercise-induced
Asthma, to alleviate symptoms
 Alternative System of Medicine:
Yogic breathing exercise technique, Pranayama, was
been shown to reduce in histamine reactivity
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50.  Avoidance of precipitating factors
 Avoid dusting when subject is around
 Avoid using carpets, stuffed toys, open bookshelves,
smoking, chemical sprays in house. Prefer mosquito nets
to repellants
 Food containing allergen to be avoided
 Maintain record of daily symptoms
*Involves avoidance of allergens and nonspecific triggers
when Asthma is established.
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51.  Rodrigo et al. Am J Med 1999
 n = 1483
 Randomized studies, double-blind, controlled
 Results:
 Pulmonary function improvement
  Hospital admission
 Stoodley et al. Ann Emerg Med 1999
 N = 1377
 Slight clinical improvement
 No side-effects

52.  Asthma is a serious global health problem affecting all
age groups
 Despite of better understanding of
 Pathophysiology
 Presence of reliable diagnostic tools,availability of a
wide range of effective & affordable drugs
 Simplified national and international asthma management
guidelines
Asthma remains poorly managed across the globe
SUMMARY

53.  Roger walker
 Rang and dales
 Goodman and Gilman's -12th The Pharmacological basis of
therapeutics
 Indian Statistics Index - www.mospi.nic.in
 http://www.cdc.gov/asthma -The Centers for Disease Control
and Prevention
 National Asthma Education and Prevention Program
http://www.nhlbi.nih.gov/about/naepp/
 Allergy and Asthma Network/Mothers of Asthmatics, Inc.
http://www.aanma.org
 Global Initiative for Asthma. Global Strategy for Asthma
Management and
Prevention, 2016. Available from: www.ginasthma.org

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