Bronchial asthma

1. Bronchial asthma
• is a chronic inflammatory disease of the airways
characterized by bronchial hyperreactivity and a
variable degree of airway obstruction.
• It is characterized by variable and recurring
symptoms, reversible airflow obstruction, and
easily triggered bronchospasms. Symptoms
include episodes of wheezing, coughing, chest
tightness, and shortness of breath.

2. Etiology
The main reasons for the development of BA are
the following Risk factors:
Internal (congenital):
• Genetic predisposition to atopy
• Airway hyperreactivity
• Obesity

3. External factors:
• Home allergens: ticks, cockroaches, animals,
mushrooms.
• Nutritional supplements.
• Environmental allergens: plant pollen.
• Professional sensitizers: food industry,
medicine.
• Tobacco smoking (active, passive).
• Air pollutants - air pollution: ozone, nitrate
oxide.
• Medicines: beta-blockers, non-steroidal anti-
inflammatory drugs.

4. Factors that trigger exacerbation
• Past viral respiratory infections.
• Exercise and hyperventilation.
• Unfavorable climatic conditions.
• Decreased immunological reactivity.
• Excessive emotional stress.

10. Diagnosis.
Complaints and anamnesis:
• Episodic attacks of suffocation, including nocturnal
episodes, presented by expiratory dyspnea,
wheezing, paroxysmal cough and chest tightness.
• Symptoms may disappear spontaneously or after
taking bronchodilator drugs (β2-agonists,
theophylline).
• Exacerbations are triggered by contact with
allergens, a viral infection, taking medications (β-
blockers, non-steroidal anti-inflammatory drugs),
physical exertion, inhaling cold air, and psycho-
emotional excitement.

11. • Seasonality of asthma attacks due to contact
with allergens.
• The presence of other atopic manifestations in
the patient (urticaria, Quincke's edema, allergic
rhinitis, etc.)
• Burdened heredity (family history of bronchial
asthma, atopic diseases).

12. Physical examination:
• Due to the variability of the manifestations of
BA, the symptoms of the disease during physical
examination may be absent. During an
exacerbation, wheezing during auscultation is
most often detected. In some patients, wheezing
can be absent or detected only during forced
expiration.

13. • However, these patients usually have other
clinical signs indicating the presence and
severity of an exacerbation (cyanosis,
drowsiness, difficulty speaking, swollen chest,
tachycardia, involvement of auxiliary muscles in
the act of breathing, and retraction of the
intercostal spaces).

14. Clinical classification (≥ 12 years old)
Severity
Symptom
frequency
Night-
time
symptom
s
%FEV1 of
predicted
FEV1vari
ability
SABA use
Mild
intermitt
ent
≤2/week
≤2/mont
h
≥80% <20%
≤2
days/wee
k
Mild
persistent
>2/week
3–
4/month
≥80% 20–30%
>2
days/wee
k
Moderate
persistent
Daily >1/week 60–80% >30% daily

15. Mandatory research methods:
• Daily monitoring of PEF (peak expiratory
flow) with the determination of variability at
home (with an individual device). The “morning
failure symptom” and PEF variability> 20% are
characteristic.
• Spirometry - allows to confirm the diagnosis
when detecting airway obstruction (decrease in
FEV1 (forced expiratory volume in 1 sek) and
FEV1 / FVC- forced vital capacity ratio).
• Note: normal spirometry does not exclude the
diagnosis of bronchial asthma.

16. • Peak flow meters are used to measure the Peak
expiratory flow rate (PEFR) , important in
both monitoring and diagnosing asthma.

17. • Normal
values for
Peak
Expiratory
Flow-PEF

18. Spirometry
• It measures lung function, specifically the
amount (volume) and/or speed (flow) of air that
can be inhaled and exhaled.
Forced expiratory volume in 1 second
(FEV1)
FEV1 is the volume of air that can forcibly be
blown out in first 1 second, after full inspiration.
FEV1/FVC ratio (FEV1%)
FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC
(forced vital capacity). In healthy adults this
should be approximately 70–85% (declining with
age).

19. • Bronchodilation test - confirms the
reversibility of bronchial obstruction - an
increase in FEV1> 12% (+200 ml) or PEFR
(Peak expiratory flow rate) > 20% (+60 L / min)
10-15 minutes after inhalation of 200-400 μg of
salbutamol.
• Note: a negative result of a bronchodilation test
does not exclude a diagnosis of bronchial
asthma.

20. • Bronchial provocative test (to determine
bronchial hyperreactivity) – decrease of:
FEV1> 20% per standard dose of methacholine
or histamine (performed only under conditions
specialized hospital with an initial indicator of
FEV1≥80%, without exacerbation).

21. Additional research:
• Chest x-ray - to exclude another pathology from
the respiratory system or to identify complications
of asthma.
• Skin allergological tests (prick-test) - in order to
clarify the allergological status.
• Pulse oximetry (in patients with signs of severe
exacerbation of the disease)
• Determination of blood gases (if possible) - if
there are signs of respiratory failure

22. Skin allergological tests

23. • Sputum eosinophils. This test looks for
certain white blood cells (eosinophils) in the
mixture of saliva and mucus (sputum) you
discharge during coughing. Eosinophils are
present when symptoms develop and become
visible when stained with a rose-colored dye.

24. • Also, during dynamic monitoring of a patient
with asthma, to assess the effectiveness of
therapy 1 month after the start of treatment, an
assessment of the level of control of bronchial
asthma is carried out according to the ACT test:
• https://getasthmahelp.org/documents/ACT_Ad
ultEng.pdf

26. Criteria for the diagnosis of asthma
• Demonstration of obstruction (FEV1/VC < 70%)
and FEV1 increase by >12% (at least 200 mL)
with respect to the initial value, measured at
least 15 min after the inhalation of four puffs of a
short-acting beta2 sympathomimetic agent, e.g.,
400 µg of salbutamol.
• Or: FEV1 worsening by >15% during, or within
30 minutes after, physical exercise (exertional
asthma)

27. • Or: FEV1 improvement by >15% after daily high-
dose administration of an inhaled corticosteroid
(ICS) for a maximum of four weeks

28. • Further diagnostic studies
Stepwise allergological testing includes skin-prick
testing, the measurement of specific IgE in serum,
and an allergen-specific nasal or bronchial
provocation test.

29. Levels of
Characteristic
control of bron
Controlled (all of
the following)
chial asthma
Partly controlled
(any measure
present in any
week)
Uncontrolled
Daytime symptoms None (twice or
less/week)
More than
twice/week
Limitations of
activities
None Any
Nocturnal
symptoms/awakeni
ng
None Any Continuous
symptoms
Need for
reliever/rescue
treatment
None (twice or
less/week)
More than
twice/week
Lung function (PEF
or FEV1)
Normal <80% predicted or
personal best (if
known)
<60%
Exacerbations
*2
None One or more/year One in any week

30. GINA’s (Global Initiative for Asthma) Strategy defines
clinically controlled asthma as follows:
• No daytime symptoms at all, or at most two
times per week
• No limitation of the activities of everyday living,
including physical exercise
• No symptoms at night, or no awakening because
of asthma
• No need for rapidly-acting bronchodilators for
symptomatic treatment ("relievers"), or at most
two times per week
• Normal or nearly normal pulmonary function
• No exacerbations.

31. Treatment of Asthma
• Control of triggers
• Drug therapy
• Monitoring
• Patient education
• Treatment of acute exacerbations

32. Non-pharmacological treatment
• Removal of allergens (especially pets with
feathers or fur)
• Structured patient education: improved self-
management leading to better symptomatic
control, reduction of the number of asthma
attacks and emergency situations, improved
quality of life, and improvement in various other
parameters of disease course including days
taken off from school or work and days spent in
hospital

33. • Physical training (reduction of asthma
symptoms, improved exercise tolerance,
improved quality of life, reduced morbidity)
• Respiratory therapy and physiotherapy (e.g.,
breathing techniques, pursed-lip breathing)
• Smoking cessation (with medical and non-
medical aids, if necessary)
• Psychosocial treatment approaches (family
therapy)
• For obese patients, weight loss

34. • The goals of pharmacotherapy are the
suppression of the inflammation of asthma and
the reduction of bronchial hyperreactivity and
airway obstruction. The medications used for
these purposes belong to groups:
• Relievers
• Controllers
• Leukotriene antagonists (montelukast)

35. Drug therapy
Major drug classes commonly used in the
treatment of asthma and asthma exacerbations
include
• Bronchodilators (beta-2 agonists,
anticholinergics)
• Corticosteroids
• Leukotriene modifiers
• Mast cell stabilizers
• Methylxanthines
• Immunomodulators

36. • The long-term pharmacotherapy of asthma in
adults. ICS, inhaled corticosteroid; LABA, long-
acting beta2 agonist; LTRA, leukotriene receptor
antagonist; RABA, rapid-acting beta2 agonist.

37. Medication Low dose Intermedia
te dose
High dose
Beclomethas
one
200–500 µg > 500–1000
µg
> 1000–
2000 µg
Budesonid 200–400 µg > 400–800
µg
> 800–1600
µg
Ciclesonide 80 µg 160 µg > 160 µg
Fluticasone 100–250 µg > 250–500
µg
> 500–1000
µg
Mometasone 200–400 µg > 400–800
µg
> 8000–
1200 µg
Daily doses of inhaled corticosteroids (ICS)

38. The main adverse effects of anti-
asthmatic medication
Inhaled short-acting beta2 sympathomimetic
agents
• Fine tremor of voluntary muscle; agitation;
tachycardia; palpitations
Inhaled long-acting beta2 sympathomimetic
agents (LABA)
• Same adverse effects as short-acting agents; also:
tolerance of bronchoprotective effect in the
presence of bronchoconstricting stimuli (while
the bronchodilating effect of the drug is
maintained); to be used over the long term only in
combination with glucocorticoids (usually ICS)

39. Inhaled corticosteroids (ICS)
• Local: oropharyngeal candidiasis (thrush);
hoarseness
• Systemic: depending on the dose and the
duration of administration, osteoporosis;
cataracts; glaucoma; delayed growth in
childhood; suppression of adrenocortical
function

40. Systemic corticosteroids
• Cushing syndrome; osteoporosis; myopathy;
glaucoma; cataracts; endocrine
psychosyndrome; worsening of diabetes
mellitus; sodium retention; hypertension;
adrenocortical atrophy; elevated susceptibility to
infection
Montelukast
• Abdominal symptoms; headache;

41. Theophyllin
• Depending on the serum concentration:
gastrointestinal disturbances; gastroesophageal
reflux disorder; tachycardia; diuresis; agitation;
insomnia. When the serum concentration
exceeds 25 mg/L: epileptic seizures;
gastrointestinal bleeding; ventricular
arrhythmia; hypotension
Omalizumab
• Local reactions at the subcutaneous injection
site; headache

42. Delivery methods
• Medications are typically provided
as metered-dose inhalers (MDIs) in
combination with an asthma spacer or
as a dry powder inhaler. The spacer is a
plastic cylinder that mixes the
medication with air, making it easier to
receive a full dose of the drug.
A nebulizer may also be used.
• Salbutamol metered dose inhaler
commonly used to treat asthma attacks.
• Fluticasone propionate metered dose
inhaler commonly used for long-term
control.

43. The prognosis for asthma
• is generally good, especially for children with mild
disease. Mortality has decreased over the last few
decades due to better recognition and improvement in
care. Of asthma diagnosed during childhood, half of
cases will no longer carry the diagnosis after a
decade. Airway remodeling is observed, but it is
unknown whether these represent harmful or beneficial
changes.