Clinically characterized by paroxysms of dysnea, cough and wheezing
Interaction among the residents and infiltrating inflammation cells in the airway surface epithelium inflamatory mediators and cytokines
Vascular Mucus production
3) Environmental and air pollution
6) Exercise rtrazine
Types of asthma
growth in the fundal height.
New strategy of asthma management are below
Bronchial asthama and pregnancys
Prof. M.C.Bansal MBBS,MS,MICOG,FICOG Professor OBGY Ex-Principal & Controller Jhalawar Medical College & HospitalMahatma Gandhi Medical College, Jaipur.
Asthma is chronic inflammatory disease of airwaycharacterized by episodic, reversible, bronchial constrictiondue to hyperresponsiveness of tracheobronchial tree to amultiple stimuli.Clinically characterized by paroxysms of dyspnea, cough wheezing
Manifested by- obstruction of airflow - damage to airway epithelium - constriction of bronchioles
Asthma and pregnancyIt is the most common chronic condition in pregnancyThe prevalence of asthma in the general population is4-5%. In pregnancy, the prevalence ranges from 1-4%.Chromosome 5, 6, 11, 12, 14, 16 & 2015 methyl PGF2 and methylergometrine should beavoided if possibleProgesterone & estrogen: bronchodilatorsProgesterone also suppresses immunity, so in thatsense it is protective or helpful
Pathogenesis & Pathophysiology Chronic inflammatory disorder of the airways with recurrent exacerbationsInteraction among the residents and infiltrating inflammation cells in the airway surface epithelium, inflamatory mediators and cytokines
Allergens Mast cell histamine leukotrienes cytokines bronchospambronchospam Mucus production Vascular permeabili ty Muscle thickening Muscle constrictionDeposition of collagen &Epithelial thickening
Stimuli of Asthma Major categories of stimuli of asthma1) Allegerns- depends on IgE response frequently seasonal , observed in childrens & adults Non seasonal form are allergy to feathers, animals danders, dust mites, molds.2) Pharmacologic stimuli like asprin, coloring agents such as tartrazine, ß-adrenergic antagonists, sulfiting agents , ACE inhibitors
3) Environmental and air pollution It includes ozone, NO2, Sulfur dioxide.4) Occupational factors high molecular weight compounds – immuniological mechanism wood , vegetable dust, pharmaceutical agents, biological agents, animals and insect dust low molecular weight compound – release bronchoconstrictor substances it includes metals salts like chromes, nickel, industrial and chemical plastics,
5) Infectionsrespiratory stmuli that evoke acute exacerbation of asthmaIn young children common is syncytial virus and Parainfluenza virusIn older children and adults rhino virus and influenza virus
6) Exercise exercise is very common precipitants of episodes of asthma .7) Emotional stress Psychological factors can version asthma8) others: some food additives like metabisulphite, tartrazine.9) Hormonal premenstrual worsening of asthma due to fall in progesterone, hypo and hyperthyroididsm can both worsen asthma10) Gastroesopahgeal reflux
Warning Signs of an Asthma Episode Examination Findings History findings in pregnant and nonpregnant patients may include the following:• Cough• Shortness of breath• Chest tightness• Noisy breathing• Nocturnal awakenings• Recurrent episodes of symptom complex• Exacerbations possibly provoked by nonspecific stimuli• Personal or family history of other atopic disease (eg, hay fever, eczema)
General physical examination findings may include the following: Tachypnea Retraction (sternomastoid, abdominal, pectoralis muscles) Agitation, usually a sign of hypoxia or respiratory distress Pulsus paradoxicus (>20 mm Hg).
Pulmonary findings are as follows: Diffuse wheezes - Long, high-pitched sounds on expiration and, occasionally, on inspiration) Diffuse rhonchi - Short, high- or low-pitched squeaks or gurgles on inspiration and/or expiration Bronchovesicular sounds Expiratory phase of respiration equal to or more prominent than inspiratory phase
Signs of fatigue and near-respiratory arrest are as follows: Alteration in the level of consciousness, such as lethargy, which is a sign of respiratory acidosis and fatigue Abdominal breathing Inability to speak in complete sentences
Signs of complicated asthma are as follows: Equality of breath sounds: Check for equality of breath sounds (pneumonia, mucous plugs, barotrauma). The amount of wheezing does not always correlate with the severity of the attack. A silent chest in someone in distress is more worrisome. Jugular venous distension from increased intrathoracic pressure (from a coexistent pneumothorax) Hypotension and tachycardia (think tension pneumothorax) Fever, a sign of upper or lower respiratory infections
Outcomes and complications of asthma in pregnancyPreeclampsiaPregnancy-induced hypertensionUterine hemorrhagePreterm laborPremature birthCongenital anomaliesFetal growth restrictionLow birth weightNeonatal hypoglycemia, seizures, tachypnea,and neonatal intensive care unit (ICU) admission
Fetal surveillance during pregnancyprimary affect on the fetus from asthma, or any otherpulmonary disease, is chronic hypoxia. The impact of hypoxia can manifest in several ways, includinggrowth restriction or more significantly, fetal death.Shortly after a woman with asthma becomes pregnant, sheshould have an early ultrasound to confirm her pregnancydating.Women should be instructed to monitor fetal activity duringthe course of the pregnancy.A third-trimester ultrasound can be considered in a womanwith well-controlled asthma who has appropriate growth inthe fundal height.
If the growth is not appropriate or the woman has an acuteexacerbation, fetal testing should be started.Testing may include umbilical artery Doppler flow velocitystudies, nonstress testing (NST) or biophysical profiles (BPP).The frequency of such testing would depend on the severity ofthe patient’s asthma or the degree of growth restriction .
Other differential diagnosis of asthma are: Upper airways obstruction laryngeal edema Acute left ventricular failure Carciniod tumors Recurrent pulmonary emboli Endobronchial disease foreign body aspiration, neoplasm & bronchial stenosis Eosinophilc pneumonias
Measures of Assessment and MonitoringTwo aspects:– Initial assessment and diagnosis of asthma– Periodic assessment and monitoring
Initial Assessment and Diagnosis of AsthmaDetermine that: Patient has history or presence of episodic symptoms of airflow obstruction Airflow obstruction is at least partially reversible Alternative diagnoses are excludedDoes patient have history or presence of episodic Symptoms of airflow obstruction? Wheeze, shortness of breath, chest tightness, or cough Asthma symptoms vary throughout the day Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma
Is airflow obstruction at least partially reversible? Use spirometry to establish airflow obstruction: – FEV1 < 80% predicted; – FEV1/FVC <65% or below the lower limit of normal Use spirometry to establish reversibility: – FEV1 increases >12% and at least 200 mL after using a short- acting inhaled beta2-agonistAre alternative diagnoses excluded? Vocal cord dysfunction, vascular rings, foreign bodies, other pulmonary diseases
Additional Tests Reasons for Additional Tests The TestsPatient has symptoms but spirometry is – Assess diurnal variation of peak flow normal or near normal over 1 to 2 weeks – Refer to a specialist for bronchoprovocation with methacholine histamine, or exercise; negative test may help rule out asthmaSuspect infection, large airway lesions, heart – Chest x-ray disease, or obstruction by foreign objectSuspect coexisting chronic obstructive pulmonary – Additional pulmonary function studies disease, restrictive defect, or central airway obstruction – Diffusing capacity testSuspect other factors contribute to asthma – Allergy tests—skin or in vitro (These are not diagnostic tests for asthma.) – Nasal examination – Gastroesophageal reflux assessment
Classification of Asthma Severity: Clinical Features Before Treatment Days With Nights With PEF or PEF Symptoms Symptoms FEV1 VariabilityStep 4 Continuous Frequent 60% >30%SeverePersistentStep 3 Daily 5/month >60%-<80% >30%ModeratePersistentStep 2 3-6/week 3-4/month 80% 20-30%MildPersistentStep 1 2/week 2/month 80% <20%MildIntermittentFootnote: The patient’s step is determined by the most severe feature.
1. Mild Intermittent Asthma •Symptoms less than twice a week •Symptoms at night less than twice a month • No symptoms between episode2. Mild Persistent • Weekly, but not daily symptoms • Episodes that may affect activity and sleep • Symptoms at night more than twice a month
3. Moderate Persistent • Daily symptoms requiring bronchodialator inhaler use • Episodes that affect activity and sleep • Symptoms at night more than once a week4. Severe Persistent • Continuous symptoms • Episodes that are frequent • Symptoms at night all the time • Activities are limited because of symptoms • Symptoms occur while on maximal therapy
New strategy of asthma management are as below GINA - 2006Characteristic Controlled Partly controlled UncontrolledDay time symptoms None(twice or less/ More then week) twice/weekLimitations of None Anyactivities Three or more features of partlyNocturnal None Any controlled asthmasymptoms/awakeni present in any weekngNeed for None(twice or less/ More thanreliever/rescue week) twice/weektreatmentLungs function normal <80% predicted or(PEF or FEV1 personal best (if knownexacerbation none One or more /year One in any week
step 1 Step 2 Step 3 Step 4 Step 5 Asthma education and environmental controlAs need rapid actingβ2 agonist As needed rapid acting β2 agonist Select one Select one Add one or more Add one or both Low dose ICS Low dose ICS + Medium or high-dose Oral glucocortico- LABA ICS + LABA steroids (lowest dose)Controller option Leukotriene modifier Medium or high dose Leukotriene modifier Anti IgE treatment ICS Low dose ICS + Sustained release leukotriene modifier theophylline Low dose ICS + sustained release theophylline
DRUGS USED IN ASTHMA Bronchodilators Anti-inflammatory Agents CorticosteroidsBeta agonists Muscarinic Methyxanthines antagonists Slow Release Anti-inflammatory inhibitors Drugs
Bronchodilators(a) Beta agonists • ß2 selective agonists e.g. albuterol given by inhalation via aerosol • stimulation of adenylyl cyclase - increases cAMP in bronchial smooth muscle - increases bronchodilation • extensively used and very effective in asthmatics • Salbutamol--- 2-4mg oral, 0.5mg im /sc, 100-200mcg/puff • Terbutaline----.25mg sc/inhalation,5mg oral. • Long acting---- salmeterol/formoterol---(9-12 hrs)- 25mcg/puff, 2 puffs B D.
(b) Muscarinic antagonists e.g. IpratropiumUse: • Ipratropium is available as pressurized aerosol • not as useful as ß2 agonists in majority of asthmatics • useful in chronic obstructive pulmonary disease
(c) Methyxanthines e.g. theophylline .100-300mg tds major therapeutic preparation = aminophylline slow iv 250-500mgUse:•administered as theophylline salt orally•diminishing use now because of more effective inhaledbronchodilators• used in patients who donít respond to anti- inflammatory agents or ß2 agonists
Anti-inflammatory Agents(a) Mast cell stabilisers--- e.g. Cromolym Na prophylactic drugs used as aerosol to inhibit antigen and exercise induced asthma no effect on smooth muscle tone or bronchospasmUse:• inhaled cromolyn prevents allergen or exercise-induced asthma• 1mg/puff,2puff qid• Nedocromil---4mg/2puff bd.
(b) Corticosteroids e.g. lipid soluble corticosteroids (beclomethazone, 100,200,250,mcg Budesonide 200-400mcg bd-qidtriamcinolone used in aerosols) Use: • used in asthma that is non-responsive to bronchodilator therapy • high dose for several weeks followed by low dose, then given alternate days C) leukotriene antagonist: --monteleukast 10 mg od zafirleukast—20 mg bd. Md001921.jpg d)Anti IgEm(Omalizumab) : s/c inj 2 to 4 weeks e)Immunotherapy
When Having a Severe AsthmaEpisode Go to the emergency room right away Signs of a severe episode Rescue or inhaler medicine doesn’t help within 15 minutes Person’s lips or fingernails are blue Person has trouble walking or talking due to shortness of breath
Immediate management:Oxygen therapy by tight fitting facemask (60%).Nebulised salbutamol 2.5 +/- 0.5mg ipratropiumStart glucocorticoid therapy - prednisolone 30-60mg p.o. or hydrocortisone 200mg i.v.Urgent chest X-ray to exclude pneumothoraxUrgent blood gasReassess in 15 min or if life-threatening features appearConsider i.v. aminophylline if life-threatening features or fails to improve after 15-30 minutes ventilation needed if PEFR continues to fall despite medical therapy, patient becoming drowsy /confused/exhausted or deteriorating blood gases
Late management: Step down initially by converting from nebulised to usual inhaled device (eg MDI) checking that their technique is adequate. Patient is discharged only when PEFR normalized (80-90% of their best) without dipping. They should also be discharged on high-dose inhaled glucocorticoid, which should continue, until they are reviewed in clinic. The latter is important in preventing early relapse.
LABOUR & DELIVERYAsthma exacerbations are rare in labor and deliverydue to the increase in serum cortisolAsthma medications should not be discontinued through laborand delivery.Prostaglandin E2 is safe for cervical ripening, as is oxytocin.The agent 15-methyl prostaglandin F2-alpha should be avoidedbecause it may cause severe bronchospasm.methylergonovine may cause dyspnea, asthma is not an absolutecontraindication, and therefore it can be used when appropriatein the management of postpartum hemorrhage.
Fentanyl is preferred to morphine and meperidine, which canrelease histamine.Epidural anesthesia is usually advised because it decreasesoxygen consumption and minute ventilation. Epiduralanesthesia also decreases the possibility of requiring generalanesthesia if an emergency cesarean becomes indicated duringlabor
Postpartum period During the postpartum period, women should initially continue the same asthma medications they required during pregnancy. Close peak flow monitoring is indicated, particularly in those with poorly controlled or moderate-to-severe asthma.