Bronchial Asthma  Definition  Patho-physiology  Diagnosis  Management

Asthma prevalence in Saudi Arabia  Children and Adolescents: 20 %  Adults : 10 %

Pathology of Asthma Inflammation Airway Hyper-responsivenessAirway Obstruction Symptoms of Asthma

Source: Peter J. Barnes, MD Mechanisms: Asthma Inflammation

During an asthma attack…

Sep-15 Asthma Microscopic Pathology Obstructed Inflammed Bronchi

Before 10 Minutes After Allergen Challenge Bronchoconstriction

Sep-15 Thick bronchi with Mucous plugs

Pathophysiology

Source: Peter J. Barnes, MD Asthma Inflammation: Cells and Mediators

ALLERGIC TRIGGERS

Triggers of Asthma (Irritants)  Infections  Chemicals  Diet/Medications  Strong Emotions  Exercise  Cold temperature  Exposure to smoke

Chronic inflammation Structural changes Acute inflammation TIMETIME Barnes PJ. Clin Exp Allergy “Real Life” Variability in Asthma symptoms subclinical

diagnosis is obvious

DIAGNOSIS OF ASTHMA  History and patterns of symptoms  Physical examination  Measurements of lung function

Bronchial Asthma Asthma is diagnosed clinically by history and P/E In case of doubt : - Spirometry - Methacholine challenge test

History  Tightness of the chest, cough & expectoration, wheeze  Comes in episodes, (recurrent )  With exposure to allergens and irritants  History of asthma attacks  Relieve using salbutamol  Allergy in skin, eyes, nose  Family history of asthma or allergy

Physical Examination  Wheeze /Rhonchi (no crackles)  Tachypnea (signs of allergy of skin, nose, eyes)  Remember Absence of symptoms at the time of examination does not exclude the diagnosis of asthma

Peak Flow Meter

Managing Asthma: Peak Expiratory Flow (PEF) Meters Allows the patient to assess the status of his or her asthma

What Types of Spirometers Are Available? SpirotelSensaireSatellite RenaissanceKoKoVitalograph 2120

Spirometry: Obstructive Disease Volume, liters Time, seconds FVC = 3.2L 94 % FEV 1 = 1.8L 66 % FEV 1 /FVC = 56% Normal Obstructive

What is Asthma ?  A chronic inflammatory disorder of the airway with Infiltration of mast cells, eosinophils and lymphocytes in response to allergens  Airway hyper-responsiveness ( twitchy airways)  Recurrent episodes of wheezing, coughing and shortness of breath  Variable and often reversible airflow limitation (airway obstruction )

 ICS = inhaled cortico-steroids budesonide, fluticasone, beclomethasone, ciclosenide, mometasone  B 2 Agonists : ( stimulants) Short acting : SABA salbutamol Long Acing : LABA: Rapid acting formeterol Non- Rapid acting salmeterol

 budesonide = Pulmicort  fluticasone = Flixotide  Ciclosenide = Alvesco

Combinations: Symbicort : budesonide + formoterol Seretide: fluticasone + salmeterol Foster: beclomethasone + formeterol

Anti-cholinergic drugs: Ipratropium (Atrovent) inhaler, solution for nebulizer Tiotropium (Spiriva) inhaler

Reliever/ Rescue Salbutamol Bronchodilator (beta 2 agonist)  Quickly relieves symptoms (within 2-3 minutes)  Not for regular use

 Anti-inflammatory  Takes time to act (1-3 hours)  Long-term effect (12-24 hours)  Only for regular use (whether well or not well) Preventer/ Controller

Controller Drugs  Inhaled steroids  Leukotriene modifiers (montelukast)  Anti-IgE (omalizumab =Xolair )  Systemic steroids

Adults Patients with Asthma

Rules of Two  Use of a quick-relief inhaler more than: 2 times per week  Awaken at night due to asthma symptoms more than: 2 times per month  Consumes a quick-relief inhaler more than: 2 times per year Need controller medication

Poor Asthma Control why ? Before increasing medications, check:  Inhaler technique  Adherence to prescribed regimen  Environmental changes  Also consider alternative diagnoses

Why inhalation therapy? Oral Slow onset of action Large dosage used Greater side effects Not useful in acute symptoms Inhaled Rapid onset of action Less amount of drug used Better tolerated Very effective

summary  Asthma can be controlled but not cured  It can present in at any age.  It produces recurrent attacks of symptoms of SOB, cough with or without wheeze  Between attacks patients with asthma lead normal lives  In most cases there is some history of allergy in the family.  Understanding the disease, learning the technique and compliance with medications is the key for good control of asthma