1. Bronchial Asthma
Definition
Patho-physiology
Diagnosis
Management

2. Asthma prevalence in Saudi Arabia
Children and Adolescents: %
Adults : %

3. Airway Hyper-responsiveness
Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma

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

5. During an asthma attack…
When exposed to an asthma trigger…
Bronchioles constrict to limit exposure to the trigger.
Mucous membrane becomes irritated and swells.
Mucous is produced to trap the irritant.
Coughing initiated to pop open bronchioles and expel the mucous build-up.
Air retention volume in alveolar sacs increases – can’t get air out or in.
CO2 build-up in alveolar sacs and in system tissues which can lead to acidosis.
The body attempts to blow off the excess CO2 – rapid shallow breathing. (hyperventilation)
Hungry for O2 and trying to get rid of CO2 at the same time.
Fatigued muscles in this effort.
If this continues, the person with asthma can die.
A person with asthma undergoes what is called “airway remodeling” – where there is permanent damage to the airways and decreased overall capacity….airway hyperactivity. A hyperactive airway is more susceptible to triggers.
Taking medication:
Rescue inhaler – dilates bronchioles, doesn’t alleviate mucous or congestion in any appreciable way
Daily corticosteroid –works to reduce airway hyperactivity

6. Asthma Microscopic Pathology
Obstructed
Inflammed
Bronchi
Nov-17

7. 10 Minutes After Allergen Challenge
Bronchoconstriction
Before
10 Minutes After Allergen Challenge

8. Thick bronchi with Mucous plugs
Nov-17

9. Pathophysiology

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

11. ALLERGIC TRIGGERS

12. Triggers of Asthma (Irritants)
Infections
Chemicals
Diet/Medications
Strong Emotions
Exercise
Cold temperature
Exposure to smoke
Examples:
Allergens: cat dander, cockroach allergens, house dust mite allergens, dog dander, fungi/molds
Infections: Rhinitis, sinusitis, and Viral infections
Diet/Medications:Aspirin sensitivity, Sulfite sensitivity, Beta Blockers
Irritants: Animal dander, Exposure to indoor chemicals, Dust, Outdoor pollutants (like ozone & PM), Mold,fungi, Pollen

14. “Real Life” Variability in Asthma
Acute inflammation
symptoms
subclinical
Chronic inflammation
Asthma is a chronic inflammatory disease with a variable course characterized by episodic attacks of acute inflammation.1 Acute inflammation in asthma is associated with bronchoconstriction, plasma exudation/edema, vasodilatation, and mucus hypersecretion. Chronic inflammation in asthma is associated with subepithelial fibrosis, smooth-muscle hyperplasia/hypertrophy, mucus gland hyperplasia, and new-vessel formation. If asthma remains uncontrolled or poorly controlled, the underlying chronic inflammation may lead to structural changes (remodelling) that reduce the extent of airway response to therapy.
1. Barnes PJ. New drugs for asthma. Clin Exp Allergy 1996;26:
Structural changes
TIME
Barnes PJ. Clin Exp Allergy 1996.

15. diagnosis is obvious

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

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

18. 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

19. 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

20. Peak Flow Meter

21. Managing Asthma: Peak Expiratory Flow (PEF) Meters
Allows the patient to assess the status of his or her asthma
These are peak expiratory flow meters. PEF meters come in different styles, but they all measure the amount of air a person can blow out in liters per minute. You set the indicator to zero, take a deep breath, put your lips around the mouthpiece and exhale as hard and fast as you can. Then you read the number on the scale.
The proper use of PEF meters can help predict asthma episodes and monitor response to therapy. The goal is to monitor the airflow consistently to recognize any changes from normal. People with asthma need to know how and when to use the PEF meter and how to record the results. 21

22. What Types of Spirometers
Are Available?
                 
Spirotel
Sensaire
Satellite
 Review types of spirometers: stand alone (base station) types, handheld, PC or PDA based types. See handout for a listing of features. Note that some use disposable flow sensors, some use permanent. All require calibrations but many of the disposable types include factory calibration using code numbers or bar codes to identify the flow table to be used. 
Spirometer Systems
Simplicity
Spirotel
MicroPlus
Renaissance
KoKo*
Vitalograph 2120
Sensaire
SpiroCard*
Satellite
Renaissance
KoKo
Vitalograph
2120

23. Spirometry: Obstructive Disease5 4
Normal 3
Volume, liters
FVC = 3.2L 94 %
FEV1 = 1.8L 66 %
FEV1/FVC = 56% 2
Obstructive 1 1 2 3 4 5 6
Time, seconds

25. 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 )

26. ICS = inhaled cortico-steroids
budesonide, fluticasone, beclomethasone, ciclosenide, mometasone
B2 Agonists : ( stimulants)
Short acting : SABA salbutamol
Long Acing : LABA:
Rapid acting formeterol
Non- Rapid acting salmeterol

27. budesonide = Pulmicort
fluticasone = Flixotide
Ciclosenide = Alvesco

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

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

31. Reliever/ Rescue Bronchodilator (beta2 agonist)
Salbutamol
Bronchodilator (beta2 agonist)
Quickly relieves symptoms (within 2-3 minutes)
Not for regular use

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

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

34. Adults Patients with Asthma

36. Need controller medication
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

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

38. 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

39. 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