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

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

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

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

5. During an asthma attack…

6. Sep-15 Asthma Microscopic Pathology Obstructed Inflammed Bronchi

7. Before 10 Minutes After Allergen Challenge Bronchoconstriction

8. Sep-15 Thick bronchi with Mucous plugs

9. Pathophysiology

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

11. ALLERGIC TRIGGERS

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

14. Chronic inflammation Structural changes Acute inflammation TIMETIME Barnes PJ. Clin Exp Allergy 1996. “Real Life” Variability in Asthma symptoms subclinical

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

22. What Types of Spirometers Are Available? SpirotelSensaireSatellite RenaissanceKoKoVitalograph 2120

23. Spirometry: Obstructive Disease Volume, liters Time, seconds 5 4 3 2 1 123456 FVC = 3.2L 94 % FEV 1 = 1.8L 66 % FEV 1 /FVC = 56% Normal Obstructive

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

32.  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

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

34. Adults Patients with Asthma

36. 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