Bronchial asthma is a chronic disease with airway inflammation as a central theme in its pathogenesis. Prevalence of this condition is gradually increasing, especially in developed countries and in countries that are getting "westernized". With early diagnosis, regular monitoring and prompt and rational treatment, most patients with asthma can lead a symptom-free life.

1. Bronchial Asthma
Dr. Shashikiran Umakanth

2. Bronchial asthma
 Asthma is a heterogeneous disease with chronic
airway inflammation
 It is defined by
 history of respiratory symptoms such as
 wheeze, shortness of breath, chest tightness and cough
 symptoms that vary over time and in intensity
 Variable, reversible, expiratory airflow limitation

3. Recurrent &
variable episodes
Airway
hyperresponsiveness
Chronic Airway
Inflammation

4. Burden of asthma
 One of the most common chronic diseases worldwide
 Estimated affected individuals - 300 million
 Prevalence is increasing in many countries, especially in
children
 Expected to rise to 400 million by 2025

5. GINA

6. Worldwide Burden in 13-14yr olds
Asthma is more common in developed
countries, specially in UK, New Zealand
and Australia
Asthma may become more frequent as
individuals adopt a more ‘Westernized’
lifestyle

7. Mortality due to asthma – 2005 & 2016

8. Aetiology
 Multifactorial
 Causes and triggers

9. Hygiene hypothesis in asthma
Growing up in a
relatively ‘clean’
environment may
predispose towards
an IgE response to
allergens

10.  Complex
 Not well
understood
Pathogenesis

12. Clinical features
 Wheezing
 Episodes of shortness of breath
 Worse during night
 Cough is sometimes predominant
 Attacks vary greatly in frequency and duration.

13. Differential diagnosis
 COPD
 ACO
 Cardiac failure (left ventricular failure)
 Acute bronchitis
 Bronchiolitis

14. Investigations
 There is no single satisfactory diagnostic test
 Lung function tests
 PEFR – peak expiratory flow rate
 Spirometry
 Asthma diagnosed when >15% improvement in FEV1 or PEFR following
inhalation of a bronchodilator.
 CO transfer test is normal

15. Spirometry
 FEV1
 FCV
 FEV1/FVC

16. Other investigations
 Exercise tests – 6-minute walk/run test
 Histamine or methacholine bronchial provocation test
 Exhaled nitric oxide - measure of airway inflammation
 Blood and sputum tests – eosinophilia
 Chest X-ray - no diagnostic features; used to exclude
complications like pneumothorax
 Skin allergy tests – to identify the allergen

17. Severity
Mild
Persistent
Moderate
Persistent
Severe
Persistent
Mild
Intermittent
>2 days/Week
but not daily
Daily
Throughout
the Day
<2 days/WeekSymptoms
3-4/Month
>1/Week
but not daily
Almost Daily<2 days/Month
Nighttime
Awakening
Minor
limitation
Some
limitation
Extreme
limitation
None
Interference
with daily life
FEV1>80%
predicted
FEV1 60-80%
predicted
FEV1<60%
predicted
FEV1>80%
predicted
Lung Function

18. Management of asthma

19. Goals of treatment
 Reduce impairment
 Freedom from symptoms, including nocturnal symptoms
 Minimal need (≤2 times /week) of inhaled short acting beta
agonists (SABAs) to relieve symptoms
 Optimization of lung function
 Maintenance of normal daily activities
 minimize absence from school or job

20. Goals of treatment
 Reduce risk
 Prevention of recurrent exacerbations and need for hospital
admissions
 Prevention of loss of lung function
 Optimization of pharmacotherapy with minimal or no adverse
effects

21. Components of management
 Routine monitoring of symptoms and lung function
 Patient & family education
 Controlling trigger factors and co-morbid conditions that
contribute to asthma severity
 Pharmacologic therapy

22. Avoidance of Allergens

23. Pharmacotherapy
 Short acting relievers
 Short-acting beta agonists (SABA)
 Long acting relievers &
controllers
 Long-acting beta agonists (LABA)
 Inhaled corticosteroids (ICS)
 Combinations of ICS + LABA
 Leukotriene modifiers
 Other bronchodilators
 Inhaled antimuscarinic
 Theophyllines
 Oral steroids
 Steroid-sparing agents
 Methotrexate
 Anti-IgE (omalizumab)
 Etanercept, infliximab

24. Drugs
 Short-acting beta agonists
(SABA)
 Salbutamol, levosalbutamol,
terbutaline
 Long-acting beta agonists
(LABA)
 Salmeterol, formoterol
 Inhaled corticosteroids
(ICS)
 Beclomethasone,
budesonide, fluticasone
 Inhaled antimuscarinic
 Ipratropium, tiotropium

25. Inhaled therapy
 The mainstay of asthma therapy
 Drugs are delivered as aerosols or powders
 delivered direct to the airways
 first-pass metabolism in the liver is avoided
 lower doses are necessary
 unwanted systemic effects are minimized

26. Delivery systems
 Metered dose inhalers
 Dry powder inhalers (Rotahaler)
 Spacers / Holding chambers
 Nebulisers

27. Nebulization

28. Mild
Persistent
Moderate
Persistent
Severe
Persistent
Very Severe
Persistent
Mild
Intermittent
≤2 days/week >2 days/week
but not daily
Daily Throughout
the Day
Debilitating
Short-Acting Beta Agonists for Symptom Relief
ICS
Low Dose
ICS
Low Dose
ICS
High Dose
+
Theophylline
Montelukast
Oral Beta Agonist
Anticholinergic
ICS
High Dose
+
Anti-IgE agents
(Omalizumab)
&
Immunosuppressants
LABA
LABA LABA
Oral
Corticosteroids
Step 1
Step 2
Step 3
Step 4
Step 5
Step
up
Step
down
Step-wise treatment

29. Acute severe asthma
 Life threatening complication
 An exacerbation of asthma that has not been controlled
by the use of standard medication
 inability to complete a sentence in one breath
 respiratory rate of ≥25 breaths/min
 tachycardia of ≥110 bpm
 PEFR <50% of predicted normal or best

30. Management
 Oxygen inhalation
 Nebulized salbutamol and ipratropium, repeatedly
 Hydrocortisone 200mg IV, every 4hr, then prednisolone
 ABG – arterial blood gas measurement; CXR
 IV terbutaline or magnesium sulphate
 ICU care

31. Prognosis in asthma
 Asthma often improves in children as they reach their
teens
 Airway inflammation is present continuously from an early age
and usually persists, even if the symptoms resolve
 Frequently returns in the second, third and fourth decades
 Early use of controller drugs
 Environmental measures

32. Further reading
http://ginasthma.org

33. Thank you