Bronchial asthma is defined as a chronic inflammatory disease with episodic and chronic symptoms of airway obstruction and hyperresponsiveness to triggers. Diagnosis and treatment involve identifying symptoms, performing objective tests, and employing a stepwise pharmacological approach using controllers and relievers such as inhaled glucocorticoids and β2-agonists. Effective asthma management requires patient education, monitoring, avoiding triggers, and routine follow-up care.

1. BRONCHIAL ASTHMA

2. DEFINITION OF ASTHMA
Episodic and/or chronic symptoms of airway
obstruction.
Bronchial hyperresponsiveness to triggers.
Evidence of at least partial reversibility of the airway
obstruction
A chronic inflammatory disease of the airways
with the following clinical features:

3. PATHOPHYSIOLOGY OF ASTHMA

4. FACTORS INFLUENCING THE DEVELOPMENT
AND EXPRESSION OF ASTHMA
 HOST FACTORS
 Genetic, e.g.,
 Genes pre-disposing to atopy
 Genes pre-disposing to airway
hyperresponsiveness
 Obesity

5. FACTORS INFLUENCING THE DEVELOPMENT
AND EXPRESSION OF ASTHMA
ENVIRONMENTAL FACTORS
 Allergens
 Indoor: Domestic mites, furred animals,
cockroach allergen
 Outdoor: Pollens, fungi (molds, yeasts)
 Infections (predominantly viral)
 Occupational sensitizers
 Tobacco smoke
 Outdoor/Indoor Air Pollution
 Exercise

6. Objective measurements
• FEV1
12% (and 200ml) increase after short
acting ß2
agonist or steroid tablets
• or FEV1
12% decrease after 6 min of
exercise, histamine or methacholine
challenge
Signs
• none (common)
• wheeze – diffuse, bilateral,
expiratory ( inspiratory)
• tachypnea
Helpful additional information
• family history of asthma
• recognised triggers
• Severity of symptoms and exacerbations
• history of worsening after aspirin/NSAID/
 blocker use
Symptoms (episodic/variable)
• wheeze
• shortness of breath
• chest tightness
• cough
Consider diagnosis of asthma in
patients with some or all of these
features
Diagnosis of Asthma

7. AIRWAY HYPERRESPONSIVENESS
 Recommended for patients with normal
spirometry to help aid in the diagnosis of
asthma
 Methacholine challenge
 It is a muscarinic receptor agonist
 Assessed by degree of drop of FEV1 after
inhalation of histamine or methacholine
 Significant drop is 20% in FEV1

8. CLASSIFICATION OF ASTHMA SEVERITY
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
The presence of one of the features of severity is sufficient to place a patient in
that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
Symptoms
Night time
Symptoms
PEF or FEV1
CLASSIFY SEVERITY
Clinical Features Before Treatment
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 of the features of severity is sufficient to place a patient in that category.
WHO . Variability of PEF means variation between morning and afternoon.

9. ASTHMA MEDICATIONS
 Controllers
 Relievers
 Controllers are medications taken daily on a
long-term basis to keep asthma under clinical
control chiefly through their anti-inflammatory
effects.
 Relievers are medications used on an as-needed
basis that act quickly to reverse
bronchoconstriction and relieve its symptoms

10. CONTROLLER MEDICATIONS
 Inhaled glucocorticoids
 Leukotriene modifiers.
 Long-acting inhaled β 2-agonists.
 Theophylline.
 Cromones: sodium cromoglycate and
nedocromil sodium.
 Anti-IgE.
 Systemic glucocorticoids

11. INHALED GLUCOCORTICOIDS
 The most effective anti-inflammatory
medications for the treatment of persistent
asthma
 Studies have demonstrated efficacy in
reducing asthma symptoms, improving
quality of life, improving lung function,
decreasing airway hyperresponsiveness,
controlling airway inflammation, reducing
frequency and severity of exacerbations, and
reducing asthma mortality.

12. MECHANISM OF ACTION
 Inhibit production of inflammatory cytokines
 Decrease number of eosinophils & mast cells
 Decrease mucous secretion
Important with concomitant beta-agonist use
Increase synthesis of ß-2 receptors

13. ADVERSE EFFECTS
 Oral candidiasis (thrush)
 Dysphonia
 Systemic effects at high doses
 Potential for pituitary-adrenal axis suppression
 Osteoporosis
 Growth rate suppression in children
 Cataract and Glaucoma

14. LONG-ACTING Β 2-AGONISTS
(LABA)
Salbutamol Salmeterol Formoterol
Dose 200 µg
2-4 puffs sos
25 – 50 µg
2p q12 (MDI)
6 µg
1p q12
Character Hydrophilic Lipophilic Hydrophilic &
Lipophilic
Onset of action Rapid
(2-5 minutes)
Delayed
(>30 minutes)
Rapid
(2-5 minutes)
Duration Short
(4-6 hours)
Long
(12 hours)
Long
(12 hours)

15. LEUKOTRIENE MODIFIERS:
CLINICAL EFFECTS
 Increase in FEV1 by 10-15%
 Reduces
 Beta-agonist use
 Daytime and nocturnal symptoms
 Often used in combination with inhaled
steroids
 Potentially first-line in mild asthma
 Treatment of choice in aspirin-sensitive
asthma

16. LEUKOTRIENE PATHWAY INHIBITORS
 Leukotriene Receptor Antagonists:
Montelukast
- oral route (better compliance in kids)
- 10 mg hs
- approved for children 6 yrs & older
- good for exercise induced asthma
Zafirlukast
- 20 mg bd
- patients must be 12 yrs & older
- liver tests needed

17. LEUKOTRIENE PATHWAY INHIBITORS
 Leukotriene Synthesis Inhibitor :
Zileuton
- blocks formation of leukotrienes from
arachidonic acid
- 600 mg qid
- occasional liver toxicity
 All three LK pathway inhibitors can be used to treat
“aspirin allergy” (but it is best to just avoid NSAIDs)
 Popularity is Montelukast > Zafirlukast > Zileuton
 not as widely
prescribed

18. RELIEVER MEDICATIONS
Rapid-acting inhaled β 2-agonists.
Systemic glucocorticosteroids.
Anticholinergics.
Theophylline.
Short-acting oral β 2-agonists.

19. ASTHMA MEDICATIONS
Inhaled medications for asthma are available as
Pressurized metered-dose inhalers (MDIs),
Dry powder inhalers (DPIs), and
Nebulized or wet aerosols

20. ADVANTAGES OF SPACER
No co-ordination required
Reduced oropharyngeal deposition
Increased drug deposition in the lungs

21. Six-Part Asthma Management
Program
1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for
Chronic Management: Adults and
Children
5. Establish Plans for Managing
Exacerbations
6. Provide Regular Follow-up Care

22. PART 1 : EDUCATE PATIENTS
• General Information
• Explain action of prescribed drugs
• Stress need for regular, long-term
therapy
• Allay fears and concerns
• Treatment diary / booklet
A for Asthma
B for bronchodilation
• Avoid exposure to risk factors

23. PART 2 : ASSESS AND MONITOR
CONTROL
 Symptom reports
Use of reliever medication
Nighttime symptoms
Activity limitations
 Spirometry for initial assessment.
 PEF monitoring at home for follow up
Daily measurement recorded in a diary
Assesses the severity and predicts worsening
 Arterial blood gas for severe exacerbations

24. PART 3: AVOID EXPOSURE TO RISK
FACTORS
 Methods to prevent onset of asthma are not yet
available but this remains an important goal
 Measures to reduce exposure to causes of asthma
exacerbations (e.g. allergens, pollutants, foods and
medications) should be implemented whenever
possible

25. PART 4: ESTABLISH MEDICATION PLANS
FOR LONG-TERM ASTHMA MANAGEMENT
 A stepwise approach to pharmacological therapy is
recommended
 The choice of treatment should be guided by:
 Severity of the patient’s asthma
 Patient’s current treatment
 Pharmacological properties and availability of the various
forms of asthma treatment
 Economic considerations

26. 
Reduce therapy

Monitor
Reliever:

Inhaled beta
agonist prn
Step 3
Plus
LTRA or
Theo SR
Oral steroids
Anti IgE
Controller:
Daily LD ICS
OR
LTRA or
Theophylline-
SR
Controller:
Daily LD ICS
plus
Daily LABA or
LTRA or
Theophylline-SR
Controller:
Daily MD/HD
ICS plus
Daily LABA
OR
PEF: >80% PEF: 60-80% PEF: <60%
PEF: 60-80%
STEP 1:
Intermittent
STEP 2:
Mild
Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
Step-down
Outcome:Control of Asthma Outcome:Best Possible Results
Step-wise Approach to Asthma Therapy
Consider
after 3-6
months
Reliever: Rapid-acting BA
LD ICS: low dose inhaled corticosteroid, LABA: long acting beta agonist, LTRA: leukotriene receptor antagonist

27. Acute Severe Asthma
• Acute severe asthma accounts for 4% of all emergency
room visits
• About 1.1 to 7.0% of patients with asthma die from an
severe asthma attack
• About 1.8 million patients visit the emergency room
annually, of which 500,000 require hospitalization

28. Levels of severity of
acute asthma exacerbations
Near fatal
asthma
Raised PaCO2 and/or requiring mechanical ventilation
Life threatening
asthma
Any one of the following in a patient with severe asthma:
PEF <33%
SpO2 <92%
PaO2 <8 kPa
normal PaCO2
silent chest
cyanosis
feeble respiratory
effort
bradycardia
dysrhythmia
hypotension
exhaustion
confusion
coma
Acute severe
asthma
Any one of:
PEF 33-50%
respiratory rate 25/min
heart rate 110/min
inability to complete sentences
in one breath
Moderate asthma
exacerbation
Increasing symptoms
PEF >50-75% best or predicted
No features of acute severe asthma
8 kpa= 60 mm Hg

29. THERAPY OF ACUTE SEVERE
ASTHMA
 Oxygen
 Inhaled B2-agonists
 Glucocorticoids
 Intravenous “bronchodilators”
 Adrenaline
 Magnesium Sulphate
 Helium
 Antibiotics and Hydration

30. Oxygen therapy
• Patients with acute severe asthma are hypoxaemic –
This should be corrected with oxygen
• Oxygen saturations of at least 92% must be achieved
• Hypercapnea indicates the development of near fatal
asthma & the need for specialist/anaesthetic
intervention

31. Β2 AGONISTS
 First Line drugs
Most effective & safest initial choice of therapy to
relieve airflow obstruction
 ISSUES
- I.V. v/s inhaled
- MDI with spacer Vs nebulizer
- Continuous Vs intermittent nebulization

32. Ipratropium Bromide
• Combining nebulised Ipratropium bromide with a
nebulised 2 agonist has shown
Greater bronchodilation
Faster recovery
Shorter duration of admission
*Nebulised Ipratropium bromide (0.5 mg 4-6 hourly)
should be added to 2 agonist for patients with acute
severe asthma

33. SYSTEMIC STEROIDS
 Used in all but the mildest exacerbations
 Onset:
Systemic steroids - 6 to 24 hrs to improve lung
functions
 Route:
I.V. and oral equally effective.
 Dose:
Medium to high dose effective

34. SYSTEMIC GLUCOCORTICOIDS
 Steroids reduce mortality, relapses, subsequent hospital
admission & requirement for 2 agonist therapy
 Prednisolone 40-50 mg daily or parenteral
hydrocortisone 400 mg daily (100 mg 6 hourly)
*Give steroid tablets in adequate doses in all cases of acute
severe asthma
‡ Continue prednisolone(1-2 mg/kg/d) 40-50 mg daily for at least
five days or until recovery

35. INHALED GLUCOCORTICOIDS
 Inhaled glucocorticosteroids can be as effective as oral
glucocorticosteroids at preventing relapses
 A high-dose of inhaled glucocorticosteroid (2.4 mg
budesonide daily in four divided doses) achieves a relapse
rate similar to 40 mg oral prednisone daily (Evidence A).
 Cost is a significant factor in the use of such high-doses of
inhaled glucocorticosteroids

36. Magnesium Sulphate
• A single dose of IV Magnesium Sulphate - safe and
effective in patients not responded to initial treatment
Repeated doses Muscle weakness,
Respiratory failure
IV magnesium sulfate (2g) improves pulmonary function

37. HELIUM OXYGEN THERAPY
 There is no routine role for this intervention. It might be
considered for patients who do not respond to standard
therapy.

38. EPINEPHRINE AND LEUKOTRIENE
MODIFIERS
 Epinephrine is not routinely indicated during asthma
exacerbations.
 There is little data to suggest a role for leukotriene
modifiers in acute asthma.

39. Antibiotics
• Antibiotic therapy is not routinely
indicated for patients with acute
severe asthma unless the suspicion
of pneumonia or other bacterial
infections
Routine use of antibiotics is not indicated for acute
severe asthma
?

40. Non-Invasive Ventilation
In severe asthma, continuous non-invasive ventilation:
• Decreases the work of breathing
• Causes bronchodilatation & decreases airway resistance
• Re-expands atelectatic lung
• Promotes removal of secretions

41. Intubation of patients with acute severe asthma is
indicated if:
• Cardiac arrest
• Impending respiratory arrest
• Deteriorating conscious state
• Progressive fatigue & hypercapnia
• Failure of Non-invasive ventilation
Invasive Ventilation (Intubation)

42. ALL WHEEZES ARE NOT DUE TO
ASTHMA!!
 Tuberculosis
 Cardiac asthma
 COPD
 Allergic bronchopulmonary aspergillosis
 Carcinoid tumours
 Eosinophilic pneumonia
 Systemic vasulitis
 Recurrent pulmonary emboli

43. TAKE HOME MESSAGES
 Asthma can be effectively controlled, although
it cannot be cured
 Effective asthma management programs include
education, objective measures of lung function,
environmental control, and pharmacologic
therapy
 A stepwise approach to pharmacologic therapy is
recommended. The aim is to accomplish the
goals of therapy with the least possible
medication

44. TAKE HOME MESSAGES
 Anything more than mild, occasional asthma is more
effectively controlled by suppressing inflammation
than by only treating acute bronchospasm
 Inhaled corticosteroids are the main controller
therapy
 LABA are not to be used as monotherapy