Asthma is a chronic inflammatory condition associated with airway hyperresponsiveness (an exaggerated airway-narrowing response to specific triggers such as viruses, allergens and exercise). Physiotherapy can provide relief from symptoms of uncontrolled asthma, including coughing, wheezing, tightness in the chest, shortness of breath and QOL.

1. ASTHMA
S H I L PA S R E E S A H A
B P T, M P T ( C A R D I O T H O R A C I C
D I S O R D E R S ) , M I A P

2. Asthma is a chronic inflammatory condition
associated with airway hyperresponsiveness
(an exaggerated airway-narrowing response to
specific triggers such as viruses, allergens and
exercise).
Leads to recurrent episodes of wheezing,
breathlessness, chest tightness and/or
coughing that can vary over time and in
intensity.
It usually presents in childhood and is
associated with other features of atopy, such
as eczema and hayfever.

3. Influenced by both genetics and
environmental exposure.
Associated with exposure to tobacco
smoke and other inflammatory gases or
particulate matter

4. Triggers for asthma
Viral respiratory
tract infections
Exercise
Gastroesophageal
reflux disease
Chronic sinusitis
Environmental
allergens
Use of aspirin,
beta-blockers
Tobacco smoke
Insects, plants,
chemical fumes
Obesity
Emotional factors
or stress

5. Asthma is associated with T helper cell type-2 (Th2) immune responses.
Elevated levels of Th2 cells in the airways release specific cytokines, including interleukin (IL)-4, IL-5,
IL-9 and IL-13, and promote eosinophilic inflammation and immunoglobulin E (IgE) production
IgE production, in turn, triggers the release of inflammatory mediators, such as histamine and cysteinyl
leukotrienes, that cause bronchospasm (contraction of the smooth muscle in the airways), edema, and
increased mucous secretion, which lead to the characteristic symptoms of asthma
The mediators and cytokines released during the early phase of an immune response to an inciting
trigger further propagate the inflammatory response (late-phase asthmatic response) that leads to
progressive airway inflammation and bronchial hyperreactivity
Over time, the airway remodeling that occurs with frequent asthma exacerbations leads to greater lung
function decline and more severe airway obstruction

6. • Assess for symptom patterns suggestive of
asthma:
− Recurrent/episodic
− Occur/worsen at night or early in the morning
− Occur/worsen upon exposure to allergens
(e.g., animal dander, pollen, dust mites) or irritants
(e.g., exercise, cold air, tobacco smoke,
infections)
− Respond to appropriate asthma therapy
Medical history
• Assess for classic symptoms of asthma:
− Wheezing
− Breathlessness
− Chest tightness
− Cough (with our without sputum)

7. History and Physical Findings
Assess for family or personal history of atopic disease (particularly allergic rhinitis)
Physical examination
• Examine for wheezing on auscultation. In life-threatening asthma, the chest may be silent,
as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.
• Examine upper respiratory tract and skin for signs of other atopic conditions.
• Drowsy unresponsive, cyanotic, and confused.
• Severe respiratory muscle fatigue.

8. Mild chest pain associated with acute exacerbations.
Many asthmatics have nocturnal coughing spells but appear normal in the daytime.
During an acute exacerbation, there may be a fine tremor in the hands due to salbutamol
use, and mild tachycardia.
Patients will show some respiratory distress, often sitting forward to splint open their airways.

9. Spirometry
At least once during diagnostic
process when FEV1 is low,
confirm that FEV1/FVC is
reduced (normally > 0.75–0.80 in
adults, > 0.90 in children)

10. Diagnostic criteria
Positive bronchodilator (BD) reversibility
test (more likely to be positive if BD is withheld
before test: SABA ≥ 4 h, LABA ≥ 15 h)
→ Adults increase in FEV1 of > 12% and
> 200 mL from baseline, 10–15 min after 200–
400 μg albuterol or equivalent (greater
confidence if increase is > 15% and > 400 mL)
→ Children increase in FEV1 of > 12%
predicted
Excessive variability in twice-daily PEF over
2 weeks
→ Adults average daily diurnal PEF variability
> 10%
→ Children average daily diurnal PEF variability
> 13%
Significant increase in lung function after
4 weeks of anti-inflammatory treatment
→ Adults increase in FEV1 by > 12% and
> 200 mL (or PEF by > 20%) from baseline after
4 weeks of treatment, outside respiratory
infections

11. • Positive exercise challenge testa → Adults fall in FEV1 of > 10% and > 200 mL from baseline
→ Children fall in FEV1 of > 12% predicted, or PEF > 15%
▪ Positive bronchial challenge test (usually only performed
in adults)
→ Fall in FEV1 from baseline of ≥ 20% with standard doses
of methacholine or histamine, or ≥ 15% with standardized
hyperventilation, hypertonic saline or mannitol challenge
▪ Excessive variation in lung function between visits (less
reliable)a
→ Adults variation in FEV1 of > 12% and > 200 mL between
visits, outside of respiratory infections
→ Children variation in FEV1 of > 12% or > 15% in
PEFc between visits (may include respiratory infections)
Allergy testing
• Perform skin tests to assess allergic status and identify possible triggers

12. History and Physical
It has the following characteristic findings on examination:
Peak expiratory flow less than 33% of personal best
Oxygen saturation less than 92%
The normal partial pressure of carbon dioxide
Silent chest
Cyanosis
Feeble respiratory effort
Bradycardia
Arrhythmias
Hypotension
Confusion, coma
Exhaustion

13. Evaluation
Urea and electrolytes (kidney function) should be taken if the patient has a high dose or repeat
salbutamol, as one of the side effects of salbutamol is to cause potassium to shift into the
intracellular space transiently, which can induce a transient, iatrogenic hypokalaemia.
 Some patients may have an elevation of serum IgE.
Arterial blood gas may reveal hypoxemia and respiratory acidosis.
An ECG will reveal sinus tachycardia, which may be due to asthma, albuterol, or theophylline.
A reduced ratio of FEV1 to FVC is indicative of airway obstruction, which is reversible with
treatment. Reversibility testing is done by giving the patient inhaled short-acting beta 2 agonists,
and after that, the spirometry test is repeated. If there is a 12% or 200ml improvement in FEV1
from the previous value, then it shows reversibility and diagnostic for bronchial asthma.
Exercise spirometry may help identify patients with exercise-induced bronchoconstriction.

14. Treatment
Conservative Measures
Measures to take include calming the patient to get them to relax, moving outside or away from the likely
source of allergen, and cooling the person. Removing clothing and washing the face and mouth to remove
allergens is sometimes done, but it is not evidence-based.
Allergen (tobacco, dust mites, animals, and pollen) avoidance can significantly improve the quality of life.
Weight reduction in obese asthmatics leads to improved control.
Monoclonal antibody therapy is indicated for patients with moderate to severe asthma who have a positive
skin test. The treatment can lower IgE levels, which in turn decreases histamine production. However, the cost
of the injections is high.
Bronchial thermoplasty is a relatively new technique that delivers thermal energy to the airway wall and
reduces the narrowing of the airways. Several studies show that it can reduce emergency visits and days
missed from school.

15. Medical
Medical management includes bronchodilators like beta-2 agonists and muscarinic antagonists (salbutamol and ipratropium bromide
respectively) and anti-inflammatories such as inhaled steroids (usually beclometasone but steroids via any route will be helpful).
There are five steps in the management of chronic asthma; treatment is started depending on the severity and then escalated or de-
escalated depending on the response to treatment.
Step 1: The Preferred controller is as needed low dose inhaled corticosteroid and formoterol.
Step 2: The preferred controllers are daily low dose inhaled corticosteroid plus as-needed short-acting beta 2 agonists.
Step 3: The preferred controllers are low dose inhaled corticosteroid and long-acting beta 2 agonists plus as-needed short-acting beta 2
agonists.
Step 4: The preferred controller is a medium-dose inhaled corticosteroid and long-acting beta 2 agonist plus as-needed short-acting
beta 2 agonists.
Step 5: High dose inhaled corticosteroid and long-acting beta 2 agonist plus long-acting muscarinic antagonist/anti-IgE.

16. Indications for admission
If a patient has received three doses of an inhaled bronchodilator and shows no response,
the following factors should be used to determine admission:
The severity of airflow obstruction
Duration of asthma
Response to medications
Adequacy of home support
Any mental illness

17. Principles of Physiotherapy
management
1. Maximize quality of life, general health and well-being
2. Reduce WOB
3. Maximize aerobic capacity and efficiency of Oxygen support
4. Optimize general muscle strength, thereby peripheral oxygen extraction

18. Physiotherapy management
1. Patient education
2. Breathing retraining
3. Aerobic exercise
4. Strengthening exercise
5. Chest wall mobility
6. ROM exercise
7. Activity pacing
8. Stress management and relaxation

19. Patient education
Education about the condition, and its trigger, self management strategies, weight control,
smoking cessation, medications, prevention of asthma attack (cold, flu prevention, flu shot,
medication, nutrition)

20. Breathing exercises and asthma
The most frequently mentioned aims of breathing exercises are to ‘normalize’ breathing
pattern by adopting a slower respiratory rate with longer expiration and reduction of
hyperventilation and hyperinflation. Training also frequently involves encouraging nasal
breathing and a diaphragmatic breathing pattern.This is based on the assumption that
patients with asthma have abnormal or dysfunctional breathing patterns.

21. Inspiratory muscle training
Inspiratory muscles can be trained for both
strength and endurance with an external resistive
device. Exercise-induced bronchoconstriction
(EIB) as well as chronic bronchoconstriction in
asthmatics is associated with increased
inspiratory muscle work. It is reasonable to
suggest that increasing the strength of the
inspiratory muscles in people with asthma may
reduce the intensity of dyspnea and improves
exercise tolerance. It is possible that a loss of
muscle mass, including the respiratory muscles,
occurs in asthmatics, related to the effects of
treatment with corticosteroids. So, it may be a
suitable target for training.

22. Physical activity
Physical training is advised to increase fitness and cardio respiratory endurance, to decrease
dyspnea and improve quality of life. To treat adults with asthma advises patients with asthma
to exercise for approximately 30 min a day to increase fitness and cardio-respiratory
endurance.
The treatment goals are promoting compliance to medication, improving exercise tolerance,
respiratory conditions and airway clearance.

23. Thank You