1. Management of Severe Asthma and COPD
PROF. ABDULAZIZ H. ALZEER

2. Learning Objectives Asthma Definition Pathophysiology
Factors that triggers Asthma
Manifestation and How To assess the severity of Asthma
Treatment
Chronic Obstructive Pulmonary Disease (COPD)
Definition
Risk Factors
Emphysema
Chronic Bronchitis
Treatment and Prevention

4. ASTHMA
Definition:
Asthma is a chronic lung disease due to inflammation of the airways resulted into airway obstruction. The obstruction is reversible.
Asthma is the most common chronic disease particularly among children.
Symptom:
Cough
Wheeze
Tightness in the chest
Shortness of breath
Sometimes nocturnal symptoms

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

6. ASTHMA
Smooth muscle contraction
Mucosal edema
Excessive secretions

7. Asthma Facts about Asthma
Asthma rates have been increasing worldwide for both adults and children, males and females and in different race and ethnicities.
It is estimated that the number of people with asthma worldwide will increase by 25% in the next 15 years.

8. Child and Adult Asthma Prevalence United States, 1980-2007
Lifetime
Current
National asthma prevalence figures come from the National Health Interview Survey (NHIS).
As seen in this graph, children have higher asthma prevalence than adults on all three measures.
12-Month
Source: National Health Interview Survey; CDC National Center for Health Statistics 8

9. Asthma Prevalence by Sex United States, 1980-2007
Female
Male
Lifetime
12-Month
Current
Since 1992, rates for women have been higher than rates for men on all three measures of asthma prevalence.
Source: National Health Interview Survey; CDC National Center for Health Statistics 9

10. ASTHMA Causes: Genetic Atopy Childhood respiratory infections
Exposure to allergens

11. ASTHMA Asthma Triggers: Types of substance Example Air pollutants
Tobacco smoke, perfumes, wood dusts, gases, chemicals, solvents, paints
Pollen
Trees, flowers, weeds, plants
Animal dander
Birds, cats, dogs
Medication
Aspirin, anti-inflammatory drugs, B-blockers
Food
Eggs, nuts, wheat

12. ASTHMA MANIFESTATION OF SEVERE ASTHMA History. of
ASTHMA MANIFESTATION OF SEVERE ASTHMA History of - Frequent use of Ventolin inhaler - Previous ICU admission - Use of steroids with no clinical response - Not responding to initial inhalation therapy at ER

13. ASTHMA SEVERE ASTHMA: Physical Examination. - HR > 115/min
ASTHMA SEVERE ASTHMA: Physical Examination - HR > 115/min - RR > 30/min - Pulsus paradoxus > 10 mmHg - Unable to speak - Cyanosis - Silent chest

14. Asthma Spirometer

15. Asthma Arterial Blood Gases Acideamia Hypoxiamia Hypercarpia
pH PCO2 PO2
↑ ↓ N or ↓
N N ↓
↓ ↑ ↓↓

16. FVC
100 75 50 25
FEV1
> 75%
NORMAL =
FVC
TIME

17. < 75% FVC 100 75 50 FEV1 25 Airway Obstruction = FEV1 FVC
TIME

18. ASTHMA Poorly controlled asthma leads to:
Increased visits to doctors, hospital ER
Hospitalizations
Limitation in daily activities
Lost work days
Lower quality of life
Death

19. ASTHMA Treatment: Patient/Doctor Relationship Educate continually
Include the family
Provide information about asthma
Provide training in self-management skills

20. ASTHMA Treatment: Exposure Risk Reduce exposure to indoor allergens
Avoid tobacco smoke
Avoid vehicle emission
Identify irritants in the workplace

21. ASTHMA Treatment - Inhaled corticosteroids
- Long-acting beta2-agonists
- Leukotrienes modifiers
Takes daily over long period of time
Used to reduced inflammation, relaxed airway muscles and improve symptoms and lung function

22. Asthma Quick Reliever Used in acute attacks
Short acting beta2- agonists
Begins to work immediately and peaks at 5-10 minutes

23. Asthma Inhalers and Spacers
Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.

24. Asthma Nebulizers Machine produces a mist of medication
Used for small children or for severe asthma
No evidence that it is more effective than an inhaler used with spacers

25. Asthma Inhaled Corticosteroids
Main stay treatment of asthma
Reduce airway inflammation

26. Asthma Anti- Ig E For treatment of moderate to severe allergic asthma
For treatment of those who do not respond to high dose of corticosteroids

27. ASTHMA Treatment of Acute Attack of Asthma: - O2 Supplementation
- Inhaled Ventolin
-Inhaled steroids
- Inhaled Atrovent
- IV Steroids
For severe cases consider:
- IV Mg SO4
- Heliox
- BiPAP
- Mechanical Ventilation – for those who do not respond the above treatments.

28. ASTHMA Non-invasive Mechanical Ventilation Treatment

30. Chronic Obstructive Pulmonary Disease (COPD)
Limitation of expiratory flow
Chronic progressive disease
Associated with airway inflammation
Generally irreversible airflow obstruction
Related to smoking

31. Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
Chronic bronchitis
Small airway disease

32. COPD
COPD Facts:
COPD is the 4th leading cause of death in the United States
COPD has higher mortality rate than asthma
Leading cause of hospitalization in the US
2nd leading cause of disability

33. COPD COPD Risk Factors Smoking: most common cause
Environmental exposure
- chemicals. Dust, fumes
- second hand smoke
Alpha-1 anti-trypsin (AAT) deficiency

34. Chronic Obstructive Pulmonary Disease (COPD)

35. COPD Alpha 1 Anti-Trypsin (AAT) - is a serine protease inhibitors
Inhibit neutrophil elastase which break down elastin
Synthesized and secreted by hepatocytes
PiZZ phenotype is associated with low plasma concentration of AAT
i.e. associated with development of emphysema

36. Emphysema

37. Emphysema

38. Emphysema

39. Emphysema

40. Emphysema

41. Emphysema

42. Chronic Bronchitis Definition
Cough for 3 months in a year for 2 consecutive year

43. Chronic Bronchitis

44. Chronic Bronchitis

45. COPD Clinical Picture Dyspnea-progressive
Cough with or without expectoration
Wheezing
Loss of weight
Hypercapnia>changes in central nervous system
Barrel chest

46. COPD

47. PURSED LIP BREATHING

48. COPD COPD Treatment Inhalers (bronchodilators)
Anti-inflammatory medications
Anti-cholinergic
Theophylline therapy
Oxygen therapy
Antibiotics
Pulmonary rehabilitation
Lifestyle changes
- give up smoking
BiPAP Therapy for severe patients

49. COPD Treatment Ventolin nebulization Steroid inhalation
Atrovent inhalation
Systemic steroid
Non-invasive mechanical ventilation if the above measures were not effective.

50. COPD

51. COPD
Home Oxygen Therapy

52. COPD Oxygen therapy For COPD with severe hypoxemia
It improves survival
It improves quality of life
Indicated in patient with PaO2 < 60 mmHg

53. COPD Non-invasive Mechanical Ventilation Treatment

54. COPD Rehabilitation program Decreased symptoms
Decreased anxiety an depression improved quality of life
Decreased hospitalization
Increase exercise capacity

55. Changes in FEV1 with Aging ( Smoker vs Non-Smoker)

56. END