BRONCHIAL ASTHMA YOUSEF ABDULLAH AL TURKI MBBS,DPHC,ABFM Associate Professor Consultant Family Medicine King Khalid University Hospital College of Medicine King Saud University

CASE SCENARIO HOW YOU WILL PROCEED DURING THIS CONSULTATION ? Khalid 14 years old come to the clinic c/o shortness of breath for one day duration. He is a known asthmatic patient for more than 8 years, he visited A/E frequently. His school performance is below average, with frequent absence from school due to his illness. HOW YOU WILL PROCEED DURING THIS CONSULTATION ?

What are your objectives in caring for bronchial asthma patient ? Prevent troublesome symptoms night and day Prevent serious attacks Require little or no reliever medication Have productive, physical, psychological, and social active lives

WHAT IS BRONCHIAL ASTHMA? Asthma is a CHRONIC INFLAMMATORY disorder of the airways. Chronically inflamed airways are hyper responsive; they become obstructed and airflow is limited by bronchoconstriction,mucus plugs, and increased inflammation when airways are exposed to various risk factors.

WHAT IS THE PREVALENCE IN SAUDI ARABIA ?

The prevalence of asthma among school children in K. S The prevalence of asthma among school children in K.S.A ( AL Frayh, et al ) Range 4%-23% Riyadh 10% Jeddah 12%

What is the Pathophysiology? Trigger Factor Mast cell Mediators : histamine,prostaglandin,leukotrienes,as well as cytokines. Inflammatory cells Sustained Inflammatory response Contraction of airway smooth muscles (Bronchoconstriction)

Pathophysiology (Cont.) Airway wall swelling (mucosal edema) Airway hyper responsiveness Chronic changes Hypertrophy of the smooth muscles, thickening of the basement membrane Airway remodeling There is good evidence that asthma occurs in families.

What are the Triggering Factors? Domestic dust mites Air pollution Tobacco smoke Occupational irritants Cockroach Animal with fur Pollen

Triggering Factors ( cont.) Respiratory (viral) infections Chemical irritants Strong emotional expressions Drugs ( aspirin, beta blockers)

CASE SCENARIO How you will approach this patient? Ahmed 6 years old come to primary care clinic with his father c/o chronic cough for the last 3 months, mainly at night . How you will approach this patient?

HOW TO DIAGNOSE BRONCHIAL ASTHMA ? Consultation skill Relevant History -Symptom -history of allergic disease -Family history -Environmental history -Exclusion of other medical condition

Diagnosis of B.A ( cont.) Relevant physical examination Investigation Do you need to do investigation? Why ? Follow up Medical record Role of Peak Flow Meter

CLASSIFY ASTHMA SEVERITY Mild intermittent Asthma (step1) Mild persistent Asthma (step2) Moderate persistent Asthma (step3) Severe persistent Asthma (step4)

How to manage and control Bronchial Asthma Educate patients to develop a partnership in asthma care Assess and monitor asthma severity Avoid exposure to trigger factors Establish individual medication plans for long term management in children and adults

How to manage and control Bronchial Asthma ( cont.) Establish individual plans to manage asthma attacks Provide regular follow up care.

Stepwise approach ( children) classification mild Intermittent Mild persistent Moderate persistent Severe persistent Minor symptoms < 1/week 1-3 /week 4-5/week Continuous exacerbation/ nocturnal < 1/month 1 /month 2-3/month > 4 /month PEF between attacks >80% 60-80% < 60% Step 1 Step 2 Step 3 Step 4

Stepwise approach ( adult) classification mild Intermittent Mild persistent Moderate persistent Severe persistent Minor symptoms < 2 /week 2-3 /week 4-5 /week Continuous exacerbation/ nocturnal < 2 /month 2-3 /month 4-5 /month > 5 /month PEF between attacks >80% 60-80% < 60% Step 1 Step 2 Step 3 Step 4

Evidence Based approach Clinical evidence http://www.clinicalevidence.org Cochrane library http://www.cochrane.org/

Evidence Based approach (example) Clinical Evidence ۩ What are the effects of treatments for chronic asthma? ۩ what are the effects of treatments for acute asthma? - Beneficial - Likely to be Beneficial - unknown effectiveness

INTERNET SITE Guidelines NHLBI/ WHO report http://www.ginasthma.com Cochrane Site: http://www.cochrane.org/ Clinical Evidence: http://www.clinicalevidence.org

QUESTIONS ????

THANK YOU WITH MY BEST REGARDS

PRACTICAL GROUP (A) - Simple clinical algorithm for management of bronchial asthma among ADULT in PHC clinic GROUP (B) - Simple clinical algorithm for management of bronchial asthma among CHILDREN in PHC clinic Group (c) - Simple clinical algorithm for management of bronchial asthma in EMERGENCY

REFERENCES and FURTHER READINGS The National Scientific Committee of Bronchial Asthma in Saudi Arabia. The National Protocol for the management of Asthma, fourth edition1424/2003. National Heart, lung, and Blood Institute, National Institute of Health. WHO workshop report. Global Strategy for Asthma Management and Prevention,2002.