Asthma
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A summarized presentation regarding the recent guidelines for the diagnosis and management of asthmas
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Asthma
- 1. ASTHMA Saad Bin Zafar Mahmood Ziauddin University
- 2. Definition • Reversible obstruction of airways due to hyper responsiveness to various immunologic and non-immunologic stimuli
- 3. Epidemiology • Common chronic lung disease in children • Boys > Girls (Before puberty) • More severe in young children
- 4. Etiology / Triggers • Respiratory infections (Viral, Mycoplasma) • Changes in weather • Emotional stress
- 5. Types of Asthma • Extrinsic Asthma ▫ Related to environmental exposures ▫ Inc. conc of IgE antibodies • Intrinsic Asthma ▫ No IgE antibodies ▫ Often in the first 2 years of life
- 6. Pathophysiology • Asthma is characterized by airway inflammation and bronchospasm • Pathologic components’ ▫ Bronchospasm ▫ Mucus production ▫ Edema ▫ Infiltration of inflammatory cells ▫ Desquamation of epithelial and inflammatory cells
- 8. Pathophysiology • Allergens bind to mast cell associated IgE • Release of mediators • Result in bronchoconstriction, edema and immune responses • Early phase reaction results in bronchoconstriction • Late phase reaction results in eosinophilic and neutrophilic infiltration
- 9. Risk factors • Poverty • Small Home / Large family • Frequent respiratory infections • Intense allergenic exposure in infancy • Poor compliance to therapy
- 10. Clinical presentation • History ▫ Cough ▫ Shortness of breath ▫ Exercise intolerance ▫ Night time symptoms ▫ Agitation ▫ Lethargy ▫ Inability to speak ▫ Decreased appetite ▫ Tripod sitting position ▫ Diaphoresis
- 11. Examination • WHEEZING • Central cyanosis • Tachypnea • Tachycardia • Pulsus paradoxus • Flaring of nostrils, use of accessory muscle of respiration and intercostal recessions • Barrel shaped chest • Harrison sulci
- 12. • In severe asthmatic attack (respiratory failure) ▫ Wheezing may disappear ▫ Bradycardia ▫ No pulsus paradoxus
- 13. Diagnosis / Investigations • Mainly clinical • CBC • CXR • ABGs • Radio-allergo-sorbent testing (RAST) • PFTs
- 14. CXR in asthma • Hyper inflated and hyper lucent lungs • Inc antero-posterior diameter of chest • Flattening of diaphragm • Heart appears narrow and elongated • More horizontal ribs
- 15. PFTs • PEFR decreased • FEV1 reduced • FEV1 / FVC reduced • RV, FRC and TLC increase • Diurnal variation in PEFR is characteristic of asthma
- 16. PEFR
- 17. Differential diagnosis • Acute bronchiolitis • Foreign body in the airway • Cystic fibrosis • Congenital malformations – Vascular ring • Cardiac asthma • Pnemonia, croup and pertussis
- 18. Complications • Delayed maturation • Below average weight and height • Pnemothorax • Pneumomediastinum
- 19. Classification of asthma on severity basis
- 20. Stepwise approach to asthma medications
- 21. Management on follow-up visits
- 22. Management – Acute attack • Oxygen (2-3 L/min) • Adequate hydration • Nebulized salbutamol (with O2) ▫ Stop salbutamol if HR > 180 • Terbutaline (SC inj) • Aminophyline (IV) ▫ To be given if already on theophyline ▫ If unable to tolerate B2 agonists • Hydrocortisone (IV) • Epinephrine (SC inj) • Antibiotics • Ventilatory support
- 23. Status asthmaticus • Continuous respiratory distress despite administration of sympathomimetic drugs with or without theophyline • Management ▫ Admit in ICU ▫ Investigations done immediately ▫ Same management as acute except Steroids given initially Ipratropium can also be used
- 24. Management – Chronic asthma • Four main components ▫ Assessment and monitoring ▫ Patient education ▫ Avoidance of triggers ▫ Pharmacologic therapy
- 25. Patient education • Improving patient skills in use of inhaler • Use of peak flow monitoring • Information about medications • When and how to respond to changes
- 26. Use of inhalers
- 29. Pharmacologic therapy • Beta 2 agonits (Short and long acting) • Theophyline • Ipratropium (used along with Beta 2 agonists) • Cromolyn and nedocromil • Leukotriene antagonists • Inhaled corticosteroids • Oral corticosteroids (short courses)
- 30. Prognosis • Good prognosis with early aggressive treatment • 50 % of asthmatic children are free of symptoms by 10-20 years • 5 % experience severe disease • In severe asthma (chronic steroid dependant disease + hospitalizations) 95% become asthmatic adults
- 31. Prevention • Reduce the risk of developing allergies • Breast feeding ▫ Reduces wheezing ▫ Protection lasts for up to 6 years • Avoidance of triggers