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• Reactive Airways Disease.
– (Top) Peribronchial thickening (white circles) seen en face shows small
donut-like rings in periphery of lungs, not normally seen.
• Contained in yellow circle are thickened bronchial walls seen in profile with a
"tram-track appearance.
– (Bottom) Close-up of left lower lung in same patient shows more donut
shaped thickened bronchial walls. (yellow arrows)
DEFINITION
• A chronic inflammatory disorder
• causing hyper- responsiveness of airways to certain stimuli,
• resulting in recurrent airflow obstruction,
• presenting as
• wheezing,
• breathlessness,
• chest tightness, &
• coughing;
• completely or partially reversible with bronchodilator or spontaneously
resolving
CLASSIFICATION
• Pathophysiological Classification
• Clinical Classification
• Classification on the bases of control
• 90% of all asthma,
• common in children,
• 80% with documented allergy.
Extrinsic
OR atopic
asthma:
• 10% of all asthma,
• common in women after 30,
• follows URTI
• symptoms persist, & difficult to
treat.
Intrinsic OR
non-atopic
asthma:
Special variants:
• Exercise induced:
• Almost all asthma patients experience it.
• Some patients have it as a precipitant.
• Reduction of FEVj ≥ 10% is diagnostic,
• Cough variant:
• Chronic cough & sputum eosinophilia.
• Mostly in young at night.
• Drug induced:
• Aspirin,
• propranolol,
• timolol
• may induce in some patients.
• Occupational:
• Agents inhaled in occupational settings-
• farmer,
• cigarette manufacturer,
• bakery worker, etc.
• Seasonal.
Intermittent:
• ≤ 2 nocturnal symptoms in a month.
• Between episodes, patient is symptom-free &
• PFT is normal.
Persistent:
• Frequent attacks, >2/month.
• In between, patient may or may not be symptom-free &
• PFT is abnormal except in mild variety.
• Severity of persistent asthma:
• Mild:
• > 2 times/month, &
• PEFR or FEVj is usually <80%-65%.
• Moderate:
• Almost daily attack, &
• PEFR/FEV1 is <65%-50%.
• Severe:
• Dyspnea continuously for ≥ 6 months, &
• PEFR or FEV1 <50%.
Acute exacerbation:
• Loss of control of any class or variant may cause mild to life-
threatening condition:
• Mild:
• Patient is dyspneic but
• can complete sentences.
• Moderate:
• Patient is dyspneic &
• cannot complete sentence in one breath.
• Severe:
• Patient is severely dyspneic,
• talks in words &
• may be restless, even unconscious
Classification on Basis of Control
• important & relevant for management of asthma.
• On basis of control, asthma can be classified as
• (i) controlled,
• (ii) partly controlled, &
• (iii) uncontrolled
PRINCIPLE OF DIAGNOSIS
• Clinical criteria:
• Cardinal feature of asthma-
• paroxysmal respiratory distress,
• recurrent cough,
• wheeze,
• chest tightness,
• recurrent attacks due to multiple stimuli.
Pulmonary function tests (PFT):
• important parameters in spirometry include
• PEFR,
• FEV1,
• FVC &
• FEV 25-75.
• In asthma,
• FEV/FVC is <0.8 (normal, 0.8-1).
• FEV1 is commonly used for assessing severity of asthma.
• FEV 25-75
• effort independent & probably more sensitive indicator of airway
obstruction.
• PEFR
• can be measured with peak expiratory flow meter, while
• for other parameters spirometer is required.
• It may be used as a diagnostic tool as well as monitoring of treatment.
Abnormality in PEFR suggestive of asthma include:
• A diurnal variation of >20%, ≤ 80% of predicted, & improvement of ≥ 20% after
bronchodilator therapy.
Bronchodilator reversibility test:
• done to differentiate obstructive defect from restrictive defect &
to differentiate asthma.
• Reversibility can be found out by FEV1 before & 30 minutes after administration of
β2-agonist aerosol.
• An ↑ of >12% in PEFR or FEV1 after aerosol therapy is strongly suggestive of
asthma.
• Failure to respond, however, does not exclude asthma.
Variability tests:
• PEFR is usually lowest in morning (6.00 AM) & highest in afternoon (6.00 PM) in
asthmatic patients.
• PEFR measurements on morning & afternoon (for-1 wk) before treatment can
establish diurnal variability,
• ↑ in variability of >20-30%, on an average, indicate ↑ bronchial responsiveness &
worsening asthma.
Laboratory criteria:
• Sputum eosinophilia,
• ↑ eosinophil count in blood
• Blood gas analysis, pH
CXR:
• Shows bilateral symmetric air trapping.
• Patches of atelectasis of various sizes due to mucous plaque is not
unusual.
• Extensive areas of collapse, consolidation suggest an alternative
diagnosis.
• X-ray is also done to exclude TB.
• CXR may be normal in asthma.
Allergy test:
• Skin test & RAST (radioallergosorbent test) have limited usefulness,
since role of desensitization therapy is not fully established.
D/D
Pulmonary
tuberculosis,
Bronchiolitis,
Bronchiolacia or
Tracheomalacia,
Foreign body
aspiration,
Hypersensitivity
pneumonitis,
Cystic fibrosis,
Recurrent
pneumonia,
GERD.
MANAGEMENT PLAN
•Management goal is to achieve clinical
control. GINA revised guideline-Rule of '2':
•Day time symptoms <2/wk
•Nocturnal symptoms <2/mo
•Number of reliever drug <2/yr (salbutamol
canister)
•No exacerbation
•Normal or near N lung function
•No limitation of daily activities
Management of Asthma at Home
•First aid for asthma-"Rule of 5"
•Ensure patient is sitting comfortably
upright, be calm, & reassuring
•Give 5 puffs of reliever inhaler with spacer
direct through mouthpiece
•Wait for 5 minutes
•If no improvement, give another 5 puffs
•Repeat process for 5 times; if little/no
improvement, transfer to hospital with
puffs every 5 minutes
Traffic zone system of control:
Green zone:
• Indicated all is clear,
• PEF 80-100%, <15% variability,
• minimal symptom-patient has to continue treatment
Yellow zone:
• Indicated caution 60-80%,
• 5-25% variability,
• asthma symptom may occur-intensification/stepping up of maintenance
Red zone:
• PEF <60% &
• symptom at rest-
• immediate β2-agonist use,
• follow yellow zone if improve or report to emergency department.
TREATMENT
• Treatment of Mild Acute Asthma
• Inhaled salbutamol
• 1 puff stat, another one after 5 minutes;
• then 1-2 puffs 3-4 hourly for the next 12-24
hour. Spacer is preferable.
• If inhaled salbutamol is not available, give
oral salbutamol 0.2-0.4 mg/kg/d, 6-8 hourly
for the next 12-24 hour.
• If no improvement after 24 hour,
• advise for hospitalization for further
management.
Dehydration,
• if any, must be corrected by dextrose saline.
• Potassium may be given if hypokalemia develops.
• Usually, > 1-1.5 times maintenance fluid should be given.
• Care should be taken not to over-hydrate the patient.
Routine administration of antibiotics
• is not needed, but if
• consolidation on chest X-ray,
• blood neutrophilia, or
• presence of coarse crepitations or bronchial breath sounds,
• give antibiotics, e.g; erythromycin or amoxicillin
Chest X-ray
• should be obtained
• in all severe cases or
• when mediastinal emphysema,
• Pneumothorax, or
• pneumonia is suspected.
Sedation is hazardous.
• Tranquillizers, morphine & other opiates are contraindicated because of
their depressant effect on respiratory center.
Rescue steroid therapy:
• During step care management, patient may lose asthma control. at any
step suddenly, for example, due to viral RTI.
• No stepping up is required prior to it. Patient should follow the existing
step after ending the rescue course.
• Oral prednisolone 1-2 mg/kg/d in single morning dose or 2 dd doses for
3-14 days should be given. No tapering of this dose is needed.
PREVENTION
• Avoid triggering factors (ASTHMA), i.e.,
• Allergens
• pollen,
• dander,
• dust,
• fungal spore
• Sports
• exercises,
• games,
• traveling
• Temperature
• cold weather,
• wet, windy weather),
• Heredity
• environmental factors,
• Mites,
• Anxiety
• stress, worries
• Desensitization is not very effective, may sometimes be harmful.
Clinical
features
Mild
intermitten
t
Mild
persisten
t
Moderate
persistent
Severe
persistent
Days with
symptoms
≤ 2 wk 3-6/wk Daily Continual
Nights with
Symptoms
≤ 2/ mon 3-4/mon > 5/mon Frequent
PEFR or FEV, ≥ 80 % ≥80% > 60-80 % ≤ 60%
PEFR
variability
< 20 % 20-30 % > 30 % >30%
Mild Moderate Severe/life-threatening
episode
Symptoms
Physical exhaustion No No yes
Talk in Sentences Phrases Words/can’t talk
Feeding Able to feed
Feed with difficulty
Too breathless to feed
Signs
Consciousness ± agitated Usually agitated Agitated to drowsy
Accessory muscle use:
sternocleidomastoid
retractions
No Yes Usually prominent
Plus(/min) <100 100-160 > 160
cyanosis Absent Absent Likely to be present
Wheeze
End
expiratory
Throughout
expiration
Expiration + inspiration may
be silent chest
PEFR/FEV1 > 60 % 40-60 % < 40 %
Pulses paradoxus N may be present 20-40 mmHg
SaO2( pulse oxynetry) > 95 % 95-91 % < 91%
Level of Asthma Control
Characters Controlled ( all of
the fol;)
Partly controlled
( any measure
present in any
wk)
Uncontrolled
Daytime
symptoms
None ( twice or
less/wk)
> Twicw/wk
Limitation of
activities
None Any 3 or more
Nocturnal of
activites
None Any Or more features
of partly
need for reliever
/rescue
None ( twice or
less wk)
> Twice /wk Asthma present
Lung function
(PEFR/PEV1)
Normal < 80% predicated
or personal best
Controlled
asthma present
Scoring system for step care
management:
Do you have dyspnea everyday? Score
Do you have nocturnal attacks of
dyspnea >2 times/month? Yes = 1 No = 0
Have you suffered from dyspneic
attacks severe enough to necessitate
steroid tablets or injection,
nebulization, Inj. aminophylline or
hospitalization?
Yes = 1 No = 0
Do you have persistent dyspnea for
last6 months or more or are you
taking steroid tablets (prednisolone
etc.) for any 1 year or more?
Yes = 1 No = 0
Is patient's baseline (asymptomatic
stage) PEF ~60% of predicted value?
Yes = 1 No = 0
Total score 7-0
Step detection
Children :55 years >5 year
Score Recommended step Score Recommended step
0 Step I 0 Step I
1 Step II 1 Step II
2 Step III 2 Step III
3-6 Step IV 3 Step IVA
4 Step IVB
5-7 Step V
Long term management of Asthma
step care management
step care plan for children < 5 yrs
Childhood asthma Medication Adult asthma
Step I As per need salbutamol inhaler Step I
Step II Full-dose cromolyn or nedocromil
Step II
Step III low-dose ICS
Step IV High-dose ICS Step III
Step VA High-dose ICS + lABN
theophylline
Step IV
Step VB Step V + ora; corticosteroid Step V
Step I Step II Step III Step IV Step V
Asthma education and Environmental control
As need rapid acting β₂-agoni
Controller
option
Slect one Slect one Add one Add one/more
Low dose ICS
Low dose ICS +
LABA
Medium/high
dose ICS+ LABA
Oral
glucocorticostero
id icosteroid
Leukotriene modifier (
receptor
antagonist/synthesis
inhibitor
Medium/high
dose ICS
Leukotriene
modifier
Anti-IgG
Low dose ICS
+ leukotriene
modifier
Sustained
release
theopathyline
Low dose ICS
+ Sustained
release
theopathyline
Step care plan for > 5 yrs & adult
A 9 yr old boy presents with cough,dyspnea, restlessness & sweating.
His PR = 105/min,RR =45/min , chest is hyperinflated with ↓
movements & hyperresonent percussion note. On auscultation air
entry is bilaterally ↓ & there are widespread expiratory ronchi.
What is the
diagnosis?
Write down 2
imp;
investigations in
this case?
Give 2 common
complications of
this condition?
Write down outline of management of this child?

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Asthma Lecture For Medical Students 2.pptx

  • 1.
  • 2. • Reactive Airways Disease. – (Top) Peribronchial thickening (white circles) seen en face shows small donut-like rings in periphery of lungs, not normally seen. • Contained in yellow circle are thickened bronchial walls seen in profile with a "tram-track appearance. – (Bottom) Close-up of left lower lung in same patient shows more donut shaped thickened bronchial walls. (yellow arrows)
  • 3. DEFINITION • A chronic inflammatory disorder • causing hyper- responsiveness of airways to certain stimuli, • resulting in recurrent airflow obstruction, • presenting as • wheezing, • breathlessness, • chest tightness, & • coughing; • completely or partially reversible with bronchodilator or spontaneously resolving CLASSIFICATION • Pathophysiological Classification • Clinical Classification • Classification on the bases of control
  • 4.
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  • 6. • 90% of all asthma, • common in children, • 80% with documented allergy. Extrinsic OR atopic asthma: • 10% of all asthma, • common in women after 30, • follows URTI • symptoms persist, & difficult to treat. Intrinsic OR non-atopic asthma:
  • 7.
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  • 9. Special variants: • Exercise induced: • Almost all asthma patients experience it. • Some patients have it as a precipitant. • Reduction of FEVj ≥ 10% is diagnostic, • Cough variant: • Chronic cough & sputum eosinophilia. • Mostly in young at night. • Drug induced: • Aspirin, • propranolol, • timolol • may induce in some patients. • Occupational: • Agents inhaled in occupational settings- • farmer, • cigarette manufacturer, • bakery worker, etc. • Seasonal.
  • 10. Intermittent: • ≤ 2 nocturnal symptoms in a month. • Between episodes, patient is symptom-free & • PFT is normal. Persistent: • Frequent attacks, >2/month. • In between, patient may or may not be symptom-free & • PFT is abnormal except in mild variety. • Severity of persistent asthma: • Mild: • > 2 times/month, & • PEFR or FEVj is usually <80%-65%. • Moderate: • Almost daily attack, & • PEFR/FEV1 is <65%-50%. • Severe: • Dyspnea continuously for ≥ 6 months, & • PEFR or FEV1 <50%.
  • 11. Acute exacerbation: • Loss of control of any class or variant may cause mild to life- threatening condition: • Mild: • Patient is dyspneic but • can complete sentences. • Moderate: • Patient is dyspneic & • cannot complete sentence in one breath. • Severe: • Patient is severely dyspneic, • talks in words & • may be restless, even unconscious
  • 12.
  • 13.
  • 14. Classification on Basis of Control • important & relevant for management of asthma. • On basis of control, asthma can be classified as • (i) controlled, • (ii) partly controlled, & • (iii) uncontrolled PRINCIPLE OF DIAGNOSIS • Clinical criteria: • Cardinal feature of asthma- • paroxysmal respiratory distress, • recurrent cough, • wheeze, • chest tightness, • recurrent attacks due to multiple stimuli.
  • 15. Pulmonary function tests (PFT): • important parameters in spirometry include • PEFR, • FEV1, • FVC & • FEV 25-75. • In asthma, • FEV/FVC is <0.8 (normal, 0.8-1). • FEV1 is commonly used for assessing severity of asthma. • FEV 25-75 • effort independent & probably more sensitive indicator of airway obstruction. • PEFR • can be measured with peak expiratory flow meter, while • for other parameters spirometer is required. • It may be used as a diagnostic tool as well as monitoring of treatment.
  • 16. Abnormality in PEFR suggestive of asthma include: • A diurnal variation of >20%, ≤ 80% of predicted, & improvement of ≥ 20% after bronchodilator therapy. Bronchodilator reversibility test: • done to differentiate obstructive defect from restrictive defect & to differentiate asthma. • Reversibility can be found out by FEV1 before & 30 minutes after administration of β2-agonist aerosol. • An ↑ of >12% in PEFR or FEV1 after aerosol therapy is strongly suggestive of asthma. • Failure to respond, however, does not exclude asthma. Variability tests: • PEFR is usually lowest in morning (6.00 AM) & highest in afternoon (6.00 PM) in asthmatic patients. • PEFR measurements on morning & afternoon (for-1 wk) before treatment can establish diurnal variability, • ↑ in variability of >20-30%, on an average, indicate ↑ bronchial responsiveness & worsening asthma.
  • 17. Laboratory criteria: • Sputum eosinophilia, • ↑ eosinophil count in blood • Blood gas analysis, pH CXR: • Shows bilateral symmetric air trapping. • Patches of atelectasis of various sizes due to mucous plaque is not unusual. • Extensive areas of collapse, consolidation suggest an alternative diagnosis. • X-ray is also done to exclude TB. • CXR may be normal in asthma. Allergy test: • Skin test & RAST (radioallergosorbent test) have limited usefulness, since role of desensitization therapy is not fully established.
  • 19. MANAGEMENT PLAN •Management goal is to achieve clinical control. GINA revised guideline-Rule of '2': •Day time symptoms <2/wk •Nocturnal symptoms <2/mo •Number of reliever drug <2/yr (salbutamol canister) •No exacerbation •Normal or near N lung function •No limitation of daily activities
  • 20. Management of Asthma at Home •First aid for asthma-"Rule of 5" •Ensure patient is sitting comfortably upright, be calm, & reassuring •Give 5 puffs of reliever inhaler with spacer direct through mouthpiece •Wait for 5 minutes •If no improvement, give another 5 puffs •Repeat process for 5 times; if little/no improvement, transfer to hospital with puffs every 5 minutes
  • 21. Traffic zone system of control: Green zone: • Indicated all is clear, • PEF 80-100%, <15% variability, • minimal symptom-patient has to continue treatment Yellow zone: • Indicated caution 60-80%, • 5-25% variability, • asthma symptom may occur-intensification/stepping up of maintenance Red zone: • PEF <60% & • symptom at rest- • immediate β2-agonist use, • follow yellow zone if improve or report to emergency department.
  • 22. TREATMENT • Treatment of Mild Acute Asthma • Inhaled salbutamol • 1 puff stat, another one after 5 minutes; • then 1-2 puffs 3-4 hourly for the next 12-24 hour. Spacer is preferable. • If inhaled salbutamol is not available, give oral salbutamol 0.2-0.4 mg/kg/d, 6-8 hourly for the next 12-24 hour. • If no improvement after 24 hour, • advise for hospitalization for further management.
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  • 25. Dehydration, • if any, must be corrected by dextrose saline. • Potassium may be given if hypokalemia develops. • Usually, > 1-1.5 times maintenance fluid should be given. • Care should be taken not to over-hydrate the patient. Routine administration of antibiotics • is not needed, but if • consolidation on chest X-ray, • blood neutrophilia, or • presence of coarse crepitations or bronchial breath sounds, • give antibiotics, e.g; erythromycin or amoxicillin
  • 26. Chest X-ray • should be obtained • in all severe cases or • when mediastinal emphysema, • Pneumothorax, or • pneumonia is suspected. Sedation is hazardous. • Tranquillizers, morphine & other opiates are contraindicated because of their depressant effect on respiratory center. Rescue steroid therapy: • During step care management, patient may lose asthma control. at any step suddenly, for example, due to viral RTI. • No stepping up is required prior to it. Patient should follow the existing step after ending the rescue course. • Oral prednisolone 1-2 mg/kg/d in single morning dose or 2 dd doses for 3-14 days should be given. No tapering of this dose is needed.
  • 27. PREVENTION • Avoid triggering factors (ASTHMA), i.e., • Allergens • pollen, • dander, • dust, • fungal spore • Sports • exercises, • games, • traveling • Temperature • cold weather, • wet, windy weather), • Heredity • environmental factors, • Mites, • Anxiety • stress, worries • Desensitization is not very effective, may sometimes be harmful.
  • 28. Clinical features Mild intermitten t Mild persisten t Moderate persistent Severe persistent Days with symptoms ≤ 2 wk 3-6/wk Daily Continual Nights with Symptoms ≤ 2/ mon 3-4/mon > 5/mon Frequent PEFR or FEV, ≥ 80 % ≥80% > 60-80 % ≤ 60% PEFR variability < 20 % 20-30 % > 30 % >30%
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  • 30. Mild Moderate Severe/life-threatening episode Symptoms Physical exhaustion No No yes Talk in Sentences Phrases Words/can’t talk Feeding Able to feed Feed with difficulty Too breathless to feed Signs Consciousness ± agitated Usually agitated Agitated to drowsy Accessory muscle use: sternocleidomastoid retractions No Yes Usually prominent Plus(/min) <100 100-160 > 160 cyanosis Absent Absent Likely to be present Wheeze End expiratory Throughout expiration Expiration + inspiration may be silent chest PEFR/FEV1 > 60 % 40-60 % < 40 % Pulses paradoxus N may be present 20-40 mmHg SaO2( pulse oxynetry) > 95 % 95-91 % < 91%
  • 31. Level of Asthma Control Characters Controlled ( all of the fol;) Partly controlled ( any measure present in any wk) Uncontrolled Daytime symptoms None ( twice or less/wk) > Twicw/wk Limitation of activities None Any 3 or more Nocturnal of activites None Any Or more features of partly need for reliever /rescue None ( twice or less wk) > Twice /wk Asthma present Lung function (PEFR/PEV1) Normal < 80% predicated or personal best Controlled asthma present
  • 32. Scoring system for step care management: Do you have dyspnea everyday? Score Do you have nocturnal attacks of dyspnea >2 times/month? Yes = 1 No = 0 Have you suffered from dyspneic attacks severe enough to necessitate steroid tablets or injection, nebulization, Inj. aminophylline or hospitalization? Yes = 1 No = 0 Do you have persistent dyspnea for last6 months or more or are you taking steroid tablets (prednisolone etc.) for any 1 year or more? Yes = 1 No = 0 Is patient's baseline (asymptomatic stage) PEF ~60% of predicted value? Yes = 1 No = 0 Total score 7-0
  • 33.
  • 34. Step detection Children :55 years >5 year Score Recommended step Score Recommended step 0 Step I 0 Step I 1 Step II 1 Step II 2 Step III 2 Step III 3-6 Step IV 3 Step IVA 4 Step IVB 5-7 Step V
  • 35. Long term management of Asthma step care management step care plan for children < 5 yrs Childhood asthma Medication Adult asthma Step I As per need salbutamol inhaler Step I Step II Full-dose cromolyn or nedocromil Step II Step III low-dose ICS Step IV High-dose ICS Step III Step VA High-dose ICS + lABN theophylline Step IV Step VB Step V + ora; corticosteroid Step V
  • 36. Step I Step II Step III Step IV Step V Asthma education and Environmental control As need rapid acting β₂-agoni Controller option Slect one Slect one Add one Add one/more Low dose ICS Low dose ICS + LABA Medium/high dose ICS+ LABA Oral glucocorticostero id icosteroid Leukotriene modifier ( receptor antagonist/synthesis inhibitor Medium/high dose ICS Leukotriene modifier Anti-IgG Low dose ICS + leukotriene modifier Sustained release theopathyline Low dose ICS + Sustained release theopathyline Step care plan for > 5 yrs & adult
  • 37. A 9 yr old boy presents with cough,dyspnea, restlessness & sweating. His PR = 105/min,RR =45/min , chest is hyperinflated with ↓ movements & hyperresonent percussion note. On auscultation air entry is bilaterally ↓ & there are widespread expiratory ronchi. What is the diagnosis? Write down 2 imp; investigations in this case? Give 2 common complications of this condition? Write down outline of management of this child?