Asthma presentation
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- Asthma is a chronic lung disease characterized by airway inflammation and narrowing of the airways. It causes symptoms like wheezing, coughing, and shortness of breath. - It is diagnosed based on a patient's medical history and symptoms, and confirmed via spirometry testing which shows improved lung function after use of a bronchodilator. - Treatment involves controlling triggers, medications like inhaled corticosteroids to reduce inflammation, and managing exacerbations which involve increasing medications under a treatment plan.
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Asthma presentation
- 2. Asthma is... • Derived from the Greek word for panting or breathlessness • Recurrent airflow obstruction caused by chronic airway inflammation with a superimposed bronchospasm • Leads to… wheezing, breathlessness and a cough Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH, NHLBI. June 2002. NIH publication no. 02-5075.
- 3. Pathophysiology of Asthma • Genetic predisposition – Chromosome: 5Q31-Q33 • Results from repeated exposure to allergens in the individual already equipped with the genetic predisposition • Upon exposure to an allergen, there is a release of IgE antibodies • IgE antibody binds with the antigen
- 4. Pathophysiology of Asthma • IgE/allergen complex - then attaches itself to the mast cells on the nasal and bronchial mucosa • Release of numerous chemical mediators
- 5. Histamine • Histamine is stored mainly in the mast cell – Circulated in the blood via the basophil • Causes an increase in blood flow to the affected area. – Responsible for the increased nasal discharge, edematous mucous membranes, sneezing, itchy nose and eyes, and hives – Also associated with airway inflammation and bronchoconstriction
- 6. Asthma Triggers Smooth Muscle Dysfunction Allergens Exercise Irritants Viruses Weather Inflammation Bronchial Constriction Hypertrophy Hyperplasia Inflammatory Mediator Release Bronchial Hyperreactivity Symptoms Exacerbations Inflammatory Cell Infiltration Architectural Changes Mucus Secretion Epithelial Damage Edema Impaired Ciliary Function Adapted from Creticos. Adv Stud Med. 2002;2(14):499-503. Components of Asthma
- 7. Consequences of Inflammation in Asthma StimulusStimulus (Antigen, virus, pollutant, occupational agent)(Antigen, virus, pollutant, occupational agent) AcuteAcute InflammationInflammation ResolutionResolution Chronic InflammationChronic Inflammation RemodelingRemodeling (fixed changes in the(fixed changes in the structure of airway)structure of airway) Injury RepairInjury Repair ↑↑ Airway dysfunctionAirway dysfunction ““Permanently” alteredPermanently” altered lung functionlung function Altered airway physiologyAltered airway physiology ↑↑ Airflow obstructionAirflow obstruction
- 8. Asthma: Pathophysiologic Features and Changes in Airway Morphology Epithelial damage Inflammatory cell infiltration Vascular dilation Mucous gland hypertrophy and hyperplasia Edema Mucus hypersecretion Thickening of basement membrane Adapted from Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. NIH, NHLBI. 1991. NIH publication 91-3042. Airway smooth- muscle hypertrophy, hyperplasia, and bronchoconstriction Airway lumen narrowing Goblet cell hyperplasia
- 9. Cross Section of Bronchiole Showing Bronchospasm Color Atlas of Respiratory Disease. Volume 2, 1995.
- 10. AsthmaticNormal Jeffery P. In: Asthma, Academic Press 1998. Epithelial Damage in Asthma
- 11. Basement Membrane Thickening Jeffery P. In: Asthma, Academic Press 1998.
- 12. Triggers • Inhalant allergens are the most common triggers for both asthma – House dust – Pollens – Mold spores – Animal and insect emanations • Cockroach feces
- 13. Triggers • Chemicals • Perfumes • Foods – Sulfites (wine), shrimp, dried fruit, processed potatoes, beer • Viruses or infections • Cold air
- 14. Triggers • Tobacco smoke • Pollution –Work exposures • Exercise
- 15. Asthma is... • A disease of: –Inflammation • Primary Process –Hyperresponsiveness –Airway bronchoconstriction –Excessive mucous production
- 17. Diagnosis of Asthma • History and Physical Examination • Spirometry is needed to make diagnosis • Monitoring: –Peak Flow Meters
- 18. Symptoms and Signs of Asthma in Children and Adults • Coughing, particularly at night or after exercise • Wheezing • Chest tightness • SOB • Cold that lingers x months
- 19. Methods for Measuring Airway Caliber Maximum PEFR airflow achieved Home FVC, FEV1 FEF25%-75% Office/Clinic Airway Resistance Clinic/Laboratory
- 20. © 2008 Fitzgerald Health Education Associates, Inc. 20
- 21. Asthma Findings • Typically, reversibility of 20% or greater after administration of a bronchodilator aerosol is consistent with asthma. Conboy-Ellis, Kathleen. Asthma: Pathogenesis and Management. The Nurse Practitioner: November 2006; Vol.31, No. 11. 24 – 39.
- 22. Asthma • Hyperinflation • Diaphragm is down to the 11th ribs • Most patients with asthma have normal x-rays
- 23. Chronic Asthma Changes • Increased AP Lateral diameter • The way you know that AP/Lat diameter is increased is by this clear space between the sternum and the ascending aorta • Flat diaphragms
- 25. 1970s–1980s Bronchoconstriction (Spirometry) 1980s–1990s Inflammation (PC20, Inflam cells, FeNO) 1990s–2000s Remodeling Relieve Symptoms Prevent Symptoms Prevent Attacks Prevent Remodeling Prevent Symptoms Prevent Attacks Evolution of Asthma Paradigms Bronchial Hyperreactivity Fixed Obstruction Symptoms
- 26. Environmental Control: A Useful but Often Ignored Step • Dust Mite Avoidance – Bed linens must be laundered 1-2 times/week – Maintain humidity at <50% – Encase pillows and mattresses – Frequent vacuuming • Remember: 30 minutes after vacuuming: increased dust mite emanations in the air • Individuals with significant asthma should avoid vacuuming or avoid the room for 30 minutes after vacuuming
- 27. Environmental Control: A Useful but Often Ignored Step • Pollen Avoidance – Air-conditioning – Minimize outdoor exposures during times of highest pollen counts – Keep bedroom windows closed – Air filters
- 28. Environmental Control • Animal Avoidance – Keep animals out of the bedroom – If the family has a cat, weekly washing of the cat significantly reduces the allergen load – May have to remove animals from home – Dry clean upholstery and carpets – Cover with an air filter any ducts leading into the bedroom
- 29. Environmental Control • Mold Avoidance – Children/adolescents with allergic rhinitis and/or asthma should not be sleeping in a damp basement – Clean moldy surfaces – Avoid houseplants – Avoid chores that involve damp grass, leaves
- 30. Environmental Control • Avoidance of Non-allergic Triggers –Strong emotions –Smoke: No smoking in house or car –Pollution –Cold air –Odors –Exercise
- 31. 31 Stepwise Approach for Managing Asthma in Patients Aged ≥12 Years: NAEPP EPR-3 Guidelines Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose inhaled corticosteroid (ICS) Alternative: Mast cell stabilizer (Cromolyn nedocromil), leukotriene receptor antagonist (LTRA), or theophylline Step 3 Preferred: Medium-dose ICS or Low-dose ICS + LABA Alternative: Low-dose ICS and either LTRA, theophylline, or zileuton Step 5 Preferred: High-dose ICS + LABA and omalizumab use can be considered for patients who have allergies. Step 4 Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS and either LTRA, theophylline, or zileuton Step 6 Preferred: High-dose ICS + LABA + oral corticosteroid and consider omalizumab for patients who have allergies Severe Persistent Moderate PersistentMild PersistentIntermittent
- 32. Step Approach to Therapy • If control is not achieved with therapy, step up the therapy • Once control is sustained for a minimum of 3 months, can consider stepping down the therapy • Regardless, therapy should be reviewed q 6 months
- 34. Acute Asthma Exacerbation • Measure FEV1 • Inhaled short acting beta 2 agonist: Up to three treatments of 2-4 puffs by MDI at 20 minute intervals OR a single nebulizer • Can repeat x 1 – 2 provided patient tolerates • Prednisone – What dose and schedule??
- 35. Management of Moderate Exacerbations: Response from ED Treatment • Good Response –Symptom relief sustained x 1hr; FEV1 or PEF ≥ 70% –D/C home –Continue SABA & oral corticosteroid –Consider inhaled corticosteroid (ICS) –Patient education / asthma action plan 35
- 36. Management of Moderate Exacerbations: Response from ED Treatment • Incomplete Response – Mild-moderate symptoms, FEV1 or PEF 40-69% – SABA, oxygen, oral or IV corticosteroids – Can D/C home • Poor Response – Marked symptoms, PEF <40% – Repeat SABA immediately – ED / 911; oral corticosteroid 36
- 37. Key Differences in the EPR-3 Report • Point of discharge –FEV1 or PEF ≥ 70% predicted –Response sustained 60 minutes after last treatment –Normal physical exam • Continued ED treatment needed –FEV1 or PEF 40-69% predicted • Consider adjunct therapies –FEV1 or PEF <40% predicted 37
- 38. Thank you for your time and attention.
Editor's Notes
- Results from repeated exposure to allergens in the individual already equipped with the genetic predisposition Release of IgE antibodies IgE binds with the antigen and attaches to the mast cells on the nasal mucosa Release of numerous chemical mediators
- Results from repeated exposure to allergens in the individual already equipped with the genetic predisposition Release of IgE antibodies IgE binds with the antigen and attaches to the mast cells on the nasal mucosa Release of numerous chemical mediators
- Histamine is stored mainly in the mast cell Circulated in the blood via the basophil Causes an increase in blood flow to the affected area. This increase in blood flow causes the introduction of more fluids to the area. Responsible for the increased nasal discharge, edematous mucous membranes, sneezing, itchy nose and eyes, and hives Also causes inflammation and bronchoconstriction of airways Remember; Asthma is a disease of primarily inflammation. This inflammation causes an increase in hyperresponsiveness and bronchoconstriction.
- Disruption of the bronchial epithelium, as shown on this slide, has both structural and functional effects that contribute to inflammation and airway wall remodelling. (Holgate, 1999)
- The deposition of collagen type III, collagen type V, and fibronectin in the lamina reticularis accounts for thickening of the basement membrane. Thickening of the basement membrane is one of several elements of airway wall thickening observed in patients dying from asthma. Inflammatory cell infiltration, increased airway smooth muscle mass, and exudation of plasma with edema of the airway wall also contribute to airway wall thickening. (Fish, 1999)
- Inhalant allergens are the most common triggers for both asthma House dust, pollens, mold spores, animal and insect emanations Chemicals, perfumes, foods are other triggers Viruses or infections Cold air Occupational exposures Tobacco smoke Pollution Exercise
- Inhalant allergens are the most common triggers for both asthma House dust, pollens, mold spores, animal and insect emanations Chemicals, perfumes, foods are other triggers Viruses or infections Cold air Occupational exposures Tobacco smoke Pollution Exercise
- Inhalant allergens are the most common triggers for both asthma House dust, pollens, mold spores, animal and insect emanations Chemicals, perfumes, foods are other triggers Viruses or infections Cold air Occupational exposures Tobacco smoke Pollution Exercise
- A disease of: Inflammation Hyperresponsiveness/Bronchoconstriction Excessive mucous production
- Diagnosis of Asthma
- History and Physical Examination Pulmonary Function Tests Peak Flow Meters
- Coughing, particularly at night Wheezing Chest tightness SOB Tachypnea Restlessness Retractions Associated Symptoms Anxiety-children with asthma more likely to suffer from anxiety symptoms and disorders than non asthmatic children-study by Vila et. Al and Published in Psychosomatics: Sept 1999
- Treatment of Asthma
- Pollen counts are the highest first thing in the morning-this is when plants release their spores Also highest during breezy times of day Air filters-high efficacy units are somewhat efficacious-recommend renting the equipment prior to purchasing. Dust mites-live in bedding, mattresses and carpets. They feed on human dander and require a temp of 65-70 degrees in which to live Vacuuming-leads to 30 minutes where airborne mite feces flies through the air and becomes inhaled
- Pollen counts are the highest first thing in the morning-this is when plants release their spores Also highest during breezy times of day Air filters-high efficacy units are somewhat efficacious-recommend renting the equipment prior to purchasing. Dust mites-live in bedding, mattresses and carpets. They feed on human dander and require a temp of 65-70 degrees in which to live Vacuuming-leads to 30 minutes where airborne mite feces flies through the air and becomes inhaled
- Animal Avoidance Keep animals out of the bedroom If the family has a cat, weekly washing of the cat significantly reduces the allergen load May have to remove animals from home Mold Avoidance Children/adolescents with allergic rhinitis and/or asthma should not be sleeping in a damp basement Avoidance of Non-allergic Triggers
- Animal Avoidance Keep animals out of the bedroom If the family has a cat, weekly washing of the cat significantly reduces the allergen load May have to remove animals from home Mold Avoidance Children/adolescents with allergic rhinitis and/or asthma should not be sleeping in a damp basement Avoidance of Non-allergic Triggers
- Animal Avoidance Keep animals out of the bedroom If the family has a cat, weekly washing of the cat significantly reduces the allergen load May have to remove animals from home Mold Avoidance Children/adolescents with allergic rhinitis and/or asthma should not be sleeping in a damp basement Avoidance of Non-allergic Triggers
- Stepwise Approach for Managing Asthma in Patients Aged 12 Years: NAEPP Draft Guidelines Key Point: This slide presents the stepwise approach to therapy for patients aged 12 years. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up The horizontal bars at the top of this graphic correlate the stepwise approach to care with asthma severity, based on the draft guidelines’ tables for classifying asthma severity and initiating treatment. This is for reference purposes only, as stepping up or stepping down is based on control rather than severity The category of evidence used to support each recommendation is shown in parentheses [NAEPP p 504-510] For intermittent asthma (Step 1), a SABA should be used as needed [NAEPP p 501 lines 12-13] For exacerbations from a viral respiratory infection, a SABA may be given every 4 to 6 hours up to 24 hours, and longer with physician consult. If therapy must be repeated more frequently than every 6 weeks, a step-up in long-term care is recommended. A short course of systemic oral corticosteroids may be needed if the exacerbation is moderate to severe or the patient has a history of severe exacerbations [NAEPP p 502 lines 1-9] At Step 2 or higher (persistent asthma), daily long-term controller medication is recommended, with low- to high-dose ICS, alone or in combination, being the preferred treatment At Step 2, preferred therapy is low-dose daily ICS, and alternative (but not preferred) therapies include cromolyn, nedocromil, and LTRA, sustained-release theophylline [NAEPP p 504 lines 1-5] At Step 3, consultation with an asthma specialist may be recommended. Prior to increasing the dose, the physician should conduct a careful review of the patient’s asthma. The physician should review inhaler technique and determine whether environmental factors or comorbid conditions are attributed to the patient’s worsening of asthma [NAEPP p 505 lines 20-24 p 506 lines 1-2] There are 2 equivalent preferred therapies at Step 3: medium-dose ICS or adding a LABA to low-dose ICS. [NAEPP p 506 lines 3-11] Alternative therapies (in alphabetical order) include adding an LTRA, theophylline, or zileuton to low-dose ICS [NAEPP p 508 lines 16-17] Zileuton is a less desirable alternative because of limited studies as adjunctive therapy and the need to monitor liver function [NAEPP p 509 lines 10-14] The preferred option at Step 4 is addition of a LABA to medium-dose ICS. Alternative add-on therapies include an LTRA or theophylline [NAEPP p 509 lines 18-19; p 510 lines 4-5] At Step 5, preferred therapy is a LABA plus high-dose ICS. Omalizumab should be considered for patients with sensitivity to relevant perennial allergies. Such patients should be referred to an asthma specialist [NAEPP p 510 lines 9-14] At Step 6, oral corticosteroids are added to Step 5 therapy. [NAEPP p 510 line 16] Before oral corticosteroids are introduced, a 2-week course of oral corticosteroids (to confirm reversibility) or a combination of high-dose ICS, a LABA, and either LTRA, theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials [NAEPP p 510 lines 16-18; p 511 lines 6-10]