Bronchial Asthma is characterized by hyperresponsiveness of the airways and narrowing in response to stimuli. The document defines different types of asthma including extrinsic, intrinsic, occupational, exercise-induced, and drug-induced asthma. Diagnosis involves patient history, examination, spirometry, and challenge tests. Treatment includes avoidance of triggers, quick-relief bronchodilators, and long-term anti-inflammatory medications through a stepwise treatment approach based on asthma severity. The goals of treatment are to control symptoms, prevent exacerbations, and maintain lung function.

1. Bronchial Asthma
Presented by
Mrs. Reshma V. Pawar
Genba Sopanrao Moze College of Pharmacy, Wagholi
Pune

2. Asthma
Asthma is characterized by hyperresponsiveness of tracheo
bronchial smooth muscle to a variety of stimuli resulting
in narrowing of air tubes often accompanied by
 Increased secretion,
 Mucosal edema
 Mucus plugging
 Cough
 Bronchospasm
 Dysapnea
 Wheezing.
 Shortness of breath
 Chest tightness

3. Pathogenesis of asthma
Exposure to stimuli/ allergens/ specific condition
Production of antibody (IgE)
Release of vasoconstrictor and inflammatory substances by mast cells
Inflammation and vasoconstriction
Migration of
Phagocytic cells
Enhanced mucus secretion
Phagocytosis
Release of basic lytic Air way narrowing & obstruction
enzymes
Further inflammation Precipitation of asthma

4. Asthma Pathological Change
4

5. Types Of Asthma
Extrinsic (allergic) asthma :
More prevalent in the younger age group
It is caused by the immune system’s response to inhaled allergens.
Intrinsic (non-allergic) asthma :
It is caused by anything except an allergy.
It may be caused by an infection, stress, laughter, exercise, cold air, food
preservatives or a host of other factors.
Occupational asthma :
Occurs due to a trigger in the place of work. Common triggers include pollutants
in the air, such as smoke, chemicals, fumes, dust, or other particles.

6. Types Of Asthma
Sports asthma/Exercise-induced asthma :
Shortness of breath and coughing occurring after an exhausting exercise is termed
exercise-induced asthma.
Occur about 5-20 minutes after beginning an exercise
Precautions include using a bronchodilator inhaler just prior to the sports activity.
Drug induced asthma :
Special type of intrinsic asthma.
acute asthma attacks on first and subsequent exposure to aspirin and NSAID

7. Investigation / Diagnosis
1. Patient’s history and the symptoms being displayed
2. Patient’s family history should not be neglected, as it has a strong chance of
influencing the patient
3. A physical examination of the upper respiratory tract, Using a nasal mirror, look
inside the nose for signs of allergic disease such as increased nasal secretions,
swelling. These signs may suggest that allergies are responsible for triggering
suspected asthma.
4. Use a stethoscope to listen to the sounds the lungs make while breathing.
Wheezing sounds indicate one of the main signs of asthma: obstructed airways.

8. Investigation / Diagnosis Conti…
6. Spirometry – Breathing Test
Spirometry measures three values that are important in
diagnosing asthma:
a) Vital capacity (VC), which is the maximum amount of air that
one can inhale and exhale
b) Peak expiratory flow rate (PEFR), also known as the peak
flow rate, which is the maximum flow rate one can generate
during a forced exhalation
c) Forced expiratory volume (FEV1), which is the maximum
amount of air you one exhale in one second
If certain key measurements are below normal for a
person your age, it may be a sign that the airways are
obstructed

9. Person is asthmatic
Predicted Values Measured
Values
% Predicted
FVC 6.00 liters 4.00 liters 67 %
FEV1 5.00 liters 2.00 liters 40 %
FEV1/FVC 83 % 50% 60%
7 Challenge test - During this test, a deliberate attempt is made
to trigger airway obstruction and asthma symptoms by inhaling
an airway-constricting chemical or taking several breaths of
cold air.
8 Chest and sinus X-rays.

10. The goals of asthma management treatment
Achieve and maintain control of symptoms
Prevent asthma exacerbations
Maintain pulmonary function as close to normal as possible
Avoid adverse effects from asthma medications
Prevent development of irreversible airflow limitation
Prevent asthma mortality

11. 1. Avoidance of aggravating factors
2. Use pharmacologic agents
a) Quick relief medications:
Bronchodilators that inhibit smooth-muscle contraction
 β-Adrenergic agonists
 Methylxanthines
 anticholinergics
b) Long term control medications:
Agents that prevents or reverse inflammation
 Glucocorticoids
Management of asthma
 leukotriene inhibitors
 mast cell-stabilising agents

12.  Quick Relief Medications or Bronchodilators :
Bronchodilators relaxing the airway muscle, so opens the airways, as a result,
breathing improves.
Bronchodilators also clear mucus from the lungs.
1) β -Adrenergic agonists :
a. Short-acting inhaled form :
These are also called "quick acting " medications
These inhalers are the best for treating sudden and severe or new asthma
symptoms.
They work within 20 minutes and last four to six hours.
Available as inhalers as well as pills
Medication used in Asthma

13. Medication used in Asthma
b. Long-acting forms of beta 2-agonists :
These drugs take longer to show effect, but their benefits last longer, even up to
12 hours.
They are available as inhalers as well as pills.
When the long-acting beta-adrenergic agonists are used together with inhaled
corticosteroids, better results are obtained.
 Side effects of beta 2-agonists include :
Nervous or shaky feeling
Overexcitement or hyperactivity
Increased heart rate

14. 2) Anticholinergic drugs :
 It is available in both a metered-dose inhaler and a nebuliser solution.
 Anticholinergic drugs take about 60 minutes before they start working.
 They work best when used with a short-acting beta 2-agonist inhaler.
 Doctors use anticholinergic drugs mainly in the emergency situations in
combination with a beta-2 agonist. When used alone, anticholinergics are only
marginally effective.
 Side effects are minor, with dry throat being the most common.
Medication used in Asthma

15. 3) Theophylline:
 Available as an oral (pill and liquid) or intravenous drug.
 Theophylline and various salts; adjust dose to maintain blood level between
5-15 µg/ mL; IV (as aminophylline).
 Many drugs also alter theophylline clearance (decrease half-life: cigarettes,
phenobarbital, phenytoin; increase half-life: erythromycin, allopurinol,
cimetidine, propranolol).
Side effects include:
Nausea, Diarrohea, Imsomnia, Headache, Irregular heartbeat, Muscle cramps,
nervous feeling.
These symptoms may be a sign of having taken too much medication hence
important to check your blood levels.
Medication used in Asthma

16. Long term control medications :
1)Glucocorticoids
 Systemic or oral administration are most beneficial.
 Not useful in acute asthma.
 Agents available include beclamethasone, budesonide, flunisolide, fluticasone
proprionate, and triamcinolone acetonide.
 Combination of an inhaled steroid (fluticasone) and β2 agonist (salmeterol) is
gaining widespread use
Medication used in Asthma

17. 2) Cromoglycate sodium and nedocromil sodium :
 Useful in chronic therapy for prevention, not useful during acute attacks Because
the drugs may block acute bronchoconstriction when administered 15–20 min
before exposure to antigens, chemicals, or exercise, they may be of use in
selected patients who have predictable attacks of extrinsic asthma (exercise
induced).
 Administered as metered-dose inhaler or nebulized powder, 2 puffs daily.
3) Leukotriene modifiers :
 They are anti-inflammatory drugs, which prevent the synthesis of leukotrienes
(chemicals made by the body that cause bronchoconstriction).
 These drugs, orally taken, are used to prevent asthma attacks rather than treat
them, but can be used during an attack as well.
Medication used in Asthma

18. Inhaled Asthma Medication
Four Classes Of Asthma Drugs:
1. β2 Agonists
2. Anticholinergics
3. Cromoglycate
4. Glucocorticoids
Aerosol are of two types
1) Use drug in solution : metered dose inhaler,
nebulizer
2) Use drug dry as powder : spinhaler, rotahaler

19. Step up Therapy :
Step 1 : Occasional use of inhaled short-acting β2 adrenoreceptor
agonist bronchodilators
Inhaled short acting β2-agonist used in patients with mild intermittent
asthma (symptoms less than once a week for 3 months and fewer than two
nocturnal episodes per month)
Step 2 : Introduction of regular preventer therapy
Regular anti-inflammatory therapy (preferably ICS) should be started in addition
to inhaled β2-agonist in patient who :
has experienced an exacerbation of asthma in last 2 years uses inhaled β2-
agonist 3 times a week or more reports symptoms 3 times a week or more
is awaken by asthma one night per week.
A stepwise approach to the management of asthma

20. A stepwise approach to the management of asthma
Starting dose is 400μg Beclometasone dipropionate (BDP) per day in adult
BDP and budesonide (BUD) are approximately equivalent
Fluticasone and mometasone provide equal clinical activity to BDP/BUD at half the
dosage.
Step 3 : Add – on therapy
If patient remains poorly controlled despite regular use of ICS A further increase in the
dose of ICS may benefit Add on therapy should be considered beyond an ICS dose of
800μg/day BDP in adults Long acting β2-agonist (LABA), salmeterol and formoterol
(duration of action of at least 12 hours) LABA improve asthma control and reduce the
frequency and severity of exacerbation copare to increased dose of ICS alone.

21. A stepwise approach to the management of asthma
Combination inhalers of ICS and LABAs have been developed. Adv- more convenient,
increase compliance.Leukotriene receptor antagogonists (e.g. monteleukast 10mg daily)
are a relatively new class of agents, delivered orally.Theophyllines may be useful in
some patients but their unpredictable metabolism, drug interactions, side effects have
limited their use.
Step 4 : Continuous or frequent use of oral steroids
At this stage Prednisolone therapy (usually administered as a single daily dose in
morning) is given to control the symptoms. Patients receiving corticosteroid tablets for
more than 3 months or receiving more than 3-4 courses per year will be at risk of
systemic side-effects.

22. A stepwise approach to the management of asthma
Step down therapy :
Once asthma control is established, the dose of inhaled (or oral)
corticosteroids should be reduced to lower dose at which effective control of asthma
is maintained.

23. Exacerbations of Asthma :
Exacerbations are characterized by-
# increased symptoms
# deterioration in Peak expiratory flow
# increase in airway inflammation
Exacerbations may be precipitated by-
# infections ( most commonly viral)
# moulds ( Alternaria and Cladosporium)
# pollens (particularly following thunderstorm)
Management of mild-moderate exacerbations :
Short courses of ‘rescue’ oral corticosteroids (prednisolone 30-
60mg daily) used to regain control of symptoms. withdraw
treatment, after using for more than 3 weeks.

24. Acute severe asthma
 PEF 33-50% predicted
 Respiratory rate ≥ 25/min
 Heart rate ≥110/min
 Inability to complete sentence in 1 breath
Life-theatening features
 PEF 33-50% predicted
 SpO2<92% or PaO2< 8kPa (60mmHg), Normal PaCO2
 Silent chest
 Cyanosis
 Feeble respiratory effort
 Bradycardia or arrythmias
 Confusion
 Coma
Near-fatal asthma
 Raised PaCO2 &/or requiring mechanical ventilation
Acute severe asthma :

25. 1. Oxygen :
High concentration of oxygen (humidified if possible) to maintain the oxygen
saturation above 92% in adults.
Failure to achieve appropriate oxygenation is an indication for assisted ventilation.
2. High doses of inhaled bronchodilators :
Short acting β2-agonist administered via a nebulizer driven by oxygen
Multiple doses of salbutamol via a metered dose inhaler through a spacer
Combination of salbutamol and ipratropium bromide
3. Systemic corticosteroids :
Administered orally Prednisolone 30-60mg
IV hydrocortisone 200mg
Management of acute severe asthma

26. 4. Intravenous fluids :
Potassium supplements may be necessary because repeated doses of
salbutamol can lower serum potassium
Subsequent management :
 magnesium may provide additional bronchodilator in patients whose presenting
PE is <30% predicted
 Use of IV leukotriene receptor antagonists
Monitoring of treatment :
 PEF should be recorded every 15-30min and then every 4-6 hrs.
 Pulse oximetryb should ensure that SpO2 remains >92%
Management of acute severe asthma

27. Antiasthmatic Combinations
1) BRONKOPLUS : salbutamol 2mg, anhydrous theophylline
100mg tab.,also per 5ml syrup.
2) BRONKOTUS: Bromohexine 4mg, salbutamol 2mg tab,.also
syrup- bromohexine 4mg,salbutamol2mgper 5ml
3) TERPHYLIN: Terbutaline 2.5mg, etophylline100mg tab.
4) THEO ASTHLIN : Salbutamol 2mg, theophylline anhydrous
100mg tab.
5) THEO BRIC: Terbutaline 5mg, theophylline 100mgtab.

28. Case Study
Que. A 12-years –old girl with a childhood history of asthma
complaining of cough, dyspnea,and wheezing after visiting
a riding stable. Her symptoms became so severe that her
parents brought her to emergency room. Physical
examination revealed diaphoresis, dyspnea, tachycardia, and
tachypnea. Her respiratory rate was 42 breaths/min, pulse
rate 110beats/ min, and blood pressure 132/65mmHg.
Which treatment is appropriate for her?

29. Case Study
Ans. Inhalation of a rapid acting β2 agonist, such as albuterol,
usually provides immediate bronchodilator. An acute
asthmatic crisis often requires iv Corticosteroids, often
methylprednisolone. Inhaled beclomethasone will not
deliver enough steroid to fully combat airway inflammation.
Cromolyn can be used prophylactically to reduce
inflammatory response but is ineffective in relieving acute
symptoms

30. Case Study
Que. A 9-year-old girl has sever asthma, which required three
hospitalization in the last year. She is now receiving therapy
that has greatly reduce the frequency of these attacks.
Which of the therapies is most likely responsible for this
benefit?

31. Case Study
Ans. Administration of a corticosteroid directly to the lung
significantly reduces the frequency of severe asthma attacks.
This benefit is accomplished with minimal risk of the
severe systematic adverse effects of corticosteroid therapy.
Albuterol is only used to treat acute asthmatic episodes.The
other agents may reduce the severity of attacks but not to
the same degree or consistency as fluticasone or other
corticosteroid

32. References
I. K.D. Tripathi, Essentials of medical pharmacology,
jaypee brothers publishers,6th edition,pp.216-227.
II. Roger walker,Cate whittlesea, Clinical Pharmacy and
Therapeutics,Fourth edition, pp.367-384.
III. Richard A. Harvey, Richard Finkel.Lippincott’s
lllustrated Reviews: Pharmacology , 4th edition pp. 319-
328
IV. Nicholas A. Boon, Nicki R. Colledge,Brian R. Walker,
Davidson’s Principle and practice of medicine,20th
edition, pp.670-68.
V. http://en.wikipedia.org
VI. http://www.nlm.nih.gov/medlineplus/asthma.html