MADE FROM DAVIDSON

2. INTRODUCTION
0 Asthma is chronic inflammatory reversible disorder
with airway hyper-reactivity(AHR) and variable
airflow obstruction.
0 AHR is the tendency for airways to narrow excessively
in response to certain triggers and leads to recurrent
episodes of wheezing, chest tightness , SOB and
coughing.

4. epidemiology
0 The prevalance of asthma increased over the last
century, first in the developed and then in developing
world.
0 Current estimates suggest that asthma affects 300
million people worldwide with a predicted addition of
100 million by 2025.
0 To date, studies have explored the potential role of
indoor and outdoor allergens, microbial exposure,
diet, vitamins, breastfeeding, tobacco smoke and
obesity.

5. PATHOPHYSIOLOGY

7. RISK FACTORS
0 Hereditary
0 Allergens (pets, dust, mites, pollens)
0 Air pollutants (smoke, perfumes)
0 Infections (upper respiratory infection, sinusitis)
0 Occupational exposures
0 Environmental factors
0 Psychological factors
0 Exercise
0 Emotional stress

9. CLINICAL MANIFESTATIONS
0 WHEEZING
0 CHEST TIGHTNESS
0 BREATHLESSNESS
0 COUGH
0 HYPOXIA
0 NASAL FLARING
0 SPUTUM IS THICK
0 DECREASED OR ABSENCE OF BREATH SOUNDS
“SILENT CHEST”

10. CONT.
0 Asthma characteristically displays a “diurnal pattern”
with symptoms and lung function being worse in the
early morning.
0 Particularly when poorly controlled, symptoms such
as cough and wheeze disturb sleep and have led to the
term “nocturnal asthma”
0 Cough may be the dominant symptom in some
patients and lack of wheeze and breathlessness may
lead to a delay in reaching diagnosis of “ cough variant
asthma”

11. diagnosis
0 HISTORY TAKING: a complete family, environmental,
occupational and drug hx is essential.
0 Family hx: history of astma in family
0 Environmental hx: seasonal changes, pollen , cold and
air pollutions
0 Occupational hx: occupation relates chemicals and
compounds including metal salts , wood dust
0 Medications: aspirin or beta blockers

12. Cont.
0RESPIRATORY EXAMINATIONS:
0 Wheezing all over the lung
0 Breathlessness and cough
0 Cyanosis

13. General physical examination
Pt. with acute hx Pt. with chronic hx
0 Nasal flaring
0 Breathlessness
0 BP can be inc
0 Pulse inc
0 Cyanosis
0 Fever (sometimes)
0 R/R inc
0 Oxygen saturaton
dec
0 Eye can show s/e of
corticosteriods
0 Thrush in the mouth
0 cor pulmonale
0 Atrial fibrillation
0 Irregular pulse
0 Edema
0 Changed chest shape
with change in
breathing
0 edema

16. investigations
0 Lung function tests/pulmonary function test: shows
variable airflow limitations
0 Spirometry ,it identifies the obstructive defect, its
serevity and a baseline for bronchodilator
reversibility.
0 Peak flow meter can be used if spirometry is not
available. Patient should be advised to record reading
in the morning and before tiring in evening.

17. cont.
0 Methacholine challenge test:
it is a bronchoconstrictor which differentiates
between asthma and COPD
in asthma its positive( dec. FEV≥ 20%)
in COPD its negative (no dec. in FEV)
*CBC : EOSINOPHILIA
*SKIN TESTING: SPECIFY ALLERGENS THAT PROVOKE
BROCHOCONSTRICTION
*IgE LEVELS: inc. levels in allergic etiology aswell as
allergic bronchopulmonary aspergillosis (ABPA)
*CHEST XRAY: no diagnostic feature but exclude
pneuothorax

18. Management
0 Step 1-MILD INTERMITTENT ASTHMA: inhaled SABA
(treatment of choice)
SABA = albuterol , terbutaline
0 indicated in people with mild intermittent asthma i.e:
symptoms less than once a week for 3 months
<2 nocturnal symptoms/month

19. STEP 2- REGULAR PREVENTIVE THERAPY:
0 SABA(as needed) plus one of the following
* inhaled low dose corticosteriod(ics) preferred
choice (beclomethasone 200-800ug/day)
*leukotrine receptoantagonist=montelukast,zafirlukast
• Mast cell stabilizers= cromolyn sodium, nedocromil
0 INDICATIONS=
• exacerbation of asthma in last 2 yrs
• Used of inhaled beta agonist ≥3 times/week
• symptoms≥3 times/week
• Awakened by asthma one night/week

20. STEP 3-ADD ON THERAPY
0 SABA (AS NEEDED), plus one of the following:
• Low dose ICS+long acting beta agonist (LABA)-
PREFERRED CHOICE( salmeterol, formotertol)
• low dose ICS+ long acting anti cholinergics-
tiotropium.
• inc dose of ICS
• Low dose ICS +leukoterine antagonist- montelukast
• low dose ICS + theophylline

21. STEP 4-PERSISTENT POOR CONTROL
0 SABA( as needed), plus ≥1 of the following:
 Maximum dose of ICS(upto 2000ug/day)+ LABA
 Maximum dose of ICS+ long acting anti-cholinergics
 Add a 4th drug:
oral leukotriene antagonist or oral theophylline

22. STEP 5-SEVERE ASTHMA
0 Step-4 medications plus one of the following:
 Oral steriods-preferred option
 Anti IgE therapy
 OMALIZUMAB is a monoclonal anti IgE antibody
0 Indications are:
 Daily symptom with nocturnal symptoms
 Frequent ER admission and hospitilizations
 FEV <60%