Bronchial asthma is characterized by increased airway responsiveness leading to symptoms like dyspnea, wheezing, and cough, and is classified into various types including atopic and nonatopic. Management involves identifying triggers, pharmacotherapy for acute exacerbations, and long-term control strategies, including inhaled steroids and beta-agonists. Key diagnostic tools include spirometry, pulse oximetry, and allergy tests, with treatments adjusted based on the severity of symptoms and response to medications.

1. BRONCHIAL ASTHMA
CLINICAL FEATURES AND MANAGEMENT
Nanditha Aravind,Navya ak
Roll no:69 and 70

2. BRONCHIAL ASTHMA
• It is a group of disorders characterized by an increased
responsiveness of the airways to various stimuli.
• It manifests by widespread narrowing of the airways causing
paroxysmal dyspnea, wheezing or cough.

3. BRONCHIAL ASTHMA
PATHOPHYSIOLOGY
Airway obstruction in asthma is caused by
i) edema and inflammation of mucous membrane lining the airways
ii) excessive secretion of mucus, inflammatory cells and cellular debris
iii) spasm of the smooth muscle of bronchi. Obstruction is diffuse but not
uniform

4. BRONCHIAL ASTHMA
PATHOPHYSIOLOGY
Asthma has been classified as
1. atopic (lgE mediated, triggered by allergens)
2. nonatopic (non lgE mediated, triggered by infection)
3. mixed
4. exercise induced or aspirin induced
Inhalation of an allergen leads to a biphasic response with early and late
reactions ultimately causing bronchoconstriction.

5. BRONCHIAL ASTHMA
EARLY REACTION

6. BRONCHIAL ASTHMA
LATE REACTION
• develops 3-4 hr later and peaks at 8-12 hr.
• The release of mast cell mediators is not prevented by premedication
with beta2 -agonist.
• it is inhibited by premedication with steroids suggesting that airway
narrowing is mainly due to an inflammatory reaction and mucosal
edema.
This phase presents as clinical asthma.

7. BRONCHIAL ASTHMA
TRIGGERS
• Viral Infections
• Exercise
• Weather Changes
• Emotional factors
• Food
• Endocrine Factors

8. BRONCHIAL ASTHMA
• Dyspnea
• May develop cyanosis
• Restless
• Chest becomes barrel
shaped
• Hyperinflation of chest
• Clubbing of fingers
• Recurrent Cough
• Wheezing
• Air Hunger
• Hyper resonant chest due to air
trapping
• Prolonged Respiratory phase
• Feeble breath sounds

9. O Symptoms occur with change in season , aggravated by
exercise,and more in nights
O Acute asthma usually begins with a cold ,bouts of spasmodic
coughing

10. BRONCHIAL ASTHMA
DIFFERENTIAL DIAGNOSIS
• Bronchiolitis
• Congenital Malformation
• Aspiration of foreign body
• Hypersensitivity Pneumonitis
• Cystic Fibrosis

11. GRADING OF SEVERITY OF ACUTE
ASTHMA

12. BRONCHIAL ASTHMA
INVESTIGATIONS
• Complete blood count,ESR(normal values are expected ;may have eosinophilia
• Pulse oximetry –mild ->955,moderate-90-95%,severe<90%
• Chest X Ray-normal or show bilateral symmetric air trapping
• Patches of atelectasis of varying sizes due to mucus plugs
• Allergy Test- blood IgE elevated in atopic asthma and normal in non atopic
asthma
• Spirometry-mild ->80%,moderate -60-80%,severe<60%

13. BRONCHIAL ASTHMA
MANAGEMENT
The goals of the therapy are
1. Maintenance of near normal pulmonary function
2. Maintenance of near normal physical activity
3. Prevention of night time cough/wheeze with minimal chronic
symptoms
4. Prevention of exacerbation
5. Avoiding adverse effects of medications

14. O Management
1. Identification and elimination of exacerbating factors
2. Pharmacotherapy
i. Acute exacerbation management
ii. Long term mangement

15. ACUTE EXACERABATION OF ASTHMA
MILD
O Nebulization- salbutamol 150 mcg/kg/dose n 3 ml of saline once
O Assess for response
O Response is adequate and child is comfortable discharge on oral
salbutamol ,0.1-0.2 mg/kg/dose,6hrly or salbutamol inhaler
puffs ,2 puffs 4-6hrly
O if the child is not improving a adequately shift to the
management protocol of moderate exacerbation

16. MODERATE
Nebulized salbutamol every 20 minutes for 3 times in one hour.
Assess for response
the if the response is adequate, space out nebulization intervals
2-4hrly . observe the child for six to eight hours if the relief is
sustained discharge the child on oral salbutamol or salbutamol
inhaler 2puffs 4-6hrly

17. response is only partial start oral steroids prednisolone 1 to 2 mg /
kg / day continue nebulization .when improved (usually takes 1 to 2
days ),discharge the child on Oral salbutamol and steroid for 3 to 5
days. the child is fit for discharge if he feeds well and sleeps well
In case of deterioration manage as severe exacerbation.
if the nebulizer is not available, 2 to 4 puffs of salbutamol by MDI
every 20 minute for 3 times or subcutaneous injection of terbutaline
may be considered

18. SEVERE
Admit in the ICU
Connect to Pulse oxymeter
oxygen inhalation
oxygen driven nebulization with salbutamol and ipratropium
(125 mcg for infants and toddlers ,250 mcg for > 5 years, 500
mcg for adolescence) every 20 minutes for 3 doses .

19. IV hydrocortisone 10 mg/kg initially followed by 4 to 5
mg/kg/dose every 6hrly or IV methylprednisolone 2
mg/kg/dose or oral prednisolone 2mg/kg/day
IV MgSO4 ;0.1ml/kg 50% MgSO4 in normal infusion over 30
minute. injection aminophylline 5mg/kg/dose diluted as IV
infusion 6 hourly

20. if improvement is inadequate ,consider continuous oxygen driven nebulization
with salbutamol ,0.5 mg/kg or hourly nebulization. ipratropium can be spaced
out to 4 hourly, mixed with the corresponding doses of salbutamol
IV TERBUTALINE 10 Mcg /kg bolus infusion over 30 minute, followed by 0.4
mcg/kg/min increasing gradually, to maximum 4 mcg/kg/min
ketamine
Mechanical ventilation

21. Pharmacological
-long term
i. Assessment of symptom control
ii. Assessment of risk of exacerbation
iii. Selection of medication
iv. Selection of appropriate inhalational device
v. monitoring

22. ASSESSMENT OF SYMPTOM CONTROL
characteristics controlled Partially controlled uncontrolled
Day time symptoms none >2 per week 3 or more features of pa
rtially controlled prese
nt in week
Limitation of activity none any
nocturnal sumptoms none any
Reliever or rescue drug none >2 per week

23. Assessment of risk of
exacerbation
 MODIFIABLE
o Uncontrolled asthma symptoms
o Previous history(1 or more)
o Exposures:tobacco smoke,indoor or outdoor air
pollution,indoor allergens
o Psychological or socioeconomic problems
o Poor adherence with controlled medication
o Co- morbidities:obesity,rhinosinusitis and food allergy

24.  Non modifiable
o Ever intubated :PICU admissions
o >1 severe exacerbation requiring hospitalization in last 12
months

25. Selection of medication
O Infrequent symptoms –- No controlled medication ,short
acting beta agonist with inhaled steroids
O Asthma with any risk factors,>twice a month--low dose
inhaled steroids as and when required short acting beta
agonist
Montelukast(other choice)

26. O Troublesome – low dose inhaled steroids +long acting beta
agonist or medium dose inhaled steroids
Low or medium dose inhaled steroids +LTRA or sustained
release theophylline
O Severely uncontrolled – medium to high dose inhaled
steroids+long acting beta agonist
short course oral steroid and high dose inhaled steroids or
moderate dose inhaled steroids and long acting beta agonist

27. Selection of appropriate inhalation
device
O Metered dose inhaler(MDI)
O MDI with spacer
O With face mask
O Dry powder inhaler
O Nebulizer

28. monitoring
O Every 4-12 wks
O Detailed history(frequency of symptoms ,sleep
disturbance,physical activity,school absenteeism,visit to
doctors,need for bronchodialators)
O maintain Symptom diary
O Assessed as being controlled,partially or uncontrolled
O Poor compliance ,wrong technique of inhalation
inappropriate dose ,infections

29. O No cause is found-step up
O Control is sustained for 3-6 months,and gradual reduction-
step down

30. Step wise management

31. OLife threatening asthma:
o Cyanosis
o Silent chest
o Poor respiratory efforts
o fatigue
o Altered sensorium
o PEFR< 30 %
o Oxygen saturation <90%

32. O MDI
o Fixed amount of medication
o Aerosol form –activated
o Exacerbation and maintanance therapy
o Coordination (press and breath)
o Pressure ,oropharynx
o spacer

34. How to use

35. MDI with spacer
O Large portion being deposited in lung ,with less impaction on
oropharynx
O Advantage- overcome coordination
O Limitations-being bulky ,costly,young infants and toddlers

37. How to use
1. Remove cap ,shake ,insert into spacer
2. Place mouth piece of spacer
3. Start breathing in and out-valve
4. Breathing pattern established press canister and continue
to breath—5-10
5. Wait for 30 sec

38. With mask
O Below 2-3 yrs
HOW TO USE
O Attach baby mask
O Shake mdi inserted to mdi end
O Mouth and nose
O Press canister and encourage child to take breathing mouth
open
O 30-60

40. Nebulizer
O Acute severe asthma in young irritable and hypoxic children
O Bulky and inefficient aerosol delivery system
IMPROVE THE AMOUNT OF DRUG DELIVERED
o Total fill volume -3-5 ml
o Tapping the side of nebulizer
o Optimal flow rate -6-12L/min
o Slow,deep inhalation and breath holding

42. O Below 4 yrs-MDI with spacer and Face mask
O Above 4 yrs-MDI with spacer
O Above 12 yrs-MDI may be used directly

43. THANK YOU