2. BRONCHIAL ASTHMA prof. Mohammad Ali Khan MB, DCH, MRCP(UK) MB, DCH, MRCP(UK) Head of paediatric department Head of paediatric department SIMS/Services Hospital, Lahore.

3. BRONCHIAL ASTHMA Definition Reversible Bronchospasm Reversible Bronchospasm Hyper-reactivity Hyper-reactivity Variability Variability Allergic Disorder Allergic Disorder Chronic Inflammatory Disorder Chronic Inflammatory Disorder Mediated by eosinophils, IgE, mast cells and T-helper lymphocytes. These lymphocytes produce proallergic, proinflammatory cytokines (IL4, IL5, IL13) and chemokines.

4. PATHOGENESIS Antigen Ist exposure II exposure Y Y Ig E Ca++ Ch.mediators cAMP GMP

5. ATP C,AMPMB PD Theophylline adrenergicadrenergic C h o l i n e r g I c GMP Adrenaline Salbutamol Albuterol Salmetrol Terbutalin Ipratropium

6. Precipitating Factors Endogenous ????? Exogenous –Allergens(mostly inhaled) –Food –Infections(mostly viral URTI) –Cold –Exercise –Drugs

7. Types of Asthma 1.Triggered by Infections 2.Chronic asthma associated with allergy 3.Asthma in obese girls with early puberty 4.Occupational 5.Triad asthma

8. Clinical presentation Cough Cough Dyspnoea Dyspnoea Wheezing Wheezing Exercise intolerance Exercise intolerance Chest deformity Chest deformity

9. D/D asthma commonly wheeze but everything which wheeze is not asthma Bronchiolitis Bronchiolitis Bronchopneumonia or Bronchitis Bronchopneumonia or Bronchitis BPD BPD Foreign body Foreign body Endobronchial tuberculosis Endobronchial tuberculosis Enlarged hilar L. nodes compressing upon the main bronchus Enlarged hilar L. nodes compressing upon the main bronchus Bronchiectasis Bronchiectasis Gastroesophegeal reflux Gastroesophegeal reflux

10. Investigations CBC, ESR CBC, ESR CXR CXR S. IgE S. IgE Allergy testing Allergy testing Lung functions Lung functions –FEV1 : FVC <0.8 –Response to Bronchodilators>12% increase in FEV1 –PEFR  personal Best  Morning-to-evening variation>20% Exercise challenge Exercise challenge –Worsening in FEV1 by >15%

11. Management Acute exacerbation Acute exacerbation Chronic asthma Chronic asthma

12. Goals Of Management Maintain normal activity Maintain normal activity Normal growth Normal growth Prevent sleep disturbance Prevent sleep disturbance Prevent chronic asthma symptoms Prevent chronic asthma symptoms Keep asthma exacerbations from becoming severe Keep asthma exacerbations from becoming severe Maintain normal lung functions Maintain normal lung functions Experience little or no adverse effects of treatment Experience little or no adverse effects of treatment

13. Management Of Acute Attack Q.Does Asthma threaten life? A.Commonly not But sometimes YES. ( Mortality 0.3 /100,000 population /yr)

14. Identification SevereResp Arrest imminent imminentSymptoms DyspneaAt rest Talks inWords AlertnessAgitatedDrowsy Signs Dyspnea+++Paradoxical abd- thoracic movements. Wheeze+++Silent PulseTachycardiaBradycardia P. paradoxis>20-40 mm HgAbsent cyanosis+++++ Functional Assessment PEFR<50 PaO2<60 PaCO2>50 SPO2<90

15. Risk Factors History History –Chronic steroid dependent asthma –Prior ICU admission –Prior mechanical ventilation –Recurrent visits to ER during last 48 hrs –Poor compliance with therapy –Resp arrest/ hypoxic seizures or encephalopathy Cl/Exam Cl/Exam –Cyanosis. – Hypotension/ pulsus paradoxis. –Agitation/ drowsiness –Quiet chest Lab Lab –Hypercarbia, hypoxia, –CXR – Pneumothorax or pneumomediastinum Therapy Therapy –Over-reliance on aerosol therapy –Delayed use of systemic steroids –Sedation –Delayed admission to ICU.

16. Management: 1.O2 inhalation 2.Inhaled Salbutamol/Albuterol Nebulization or MDI 3.Inhaled Ipratropium 4.Systemic steroids 5.Aminophylline infusion 6.Heliox (70:30 mixture) 7.Mgso4 infusion (25 mg/kg in 20 min) 8.Mechanical ventilation.

17. Management of Chronic Asthma Drugs Used: 1. Beta-2 agonists 2. Non steroidal anti-inflammatory agents 3. Corticosteroids 4. Slow release theophylline 5. Leukotrine modifiers

18. Beta-2 Agonists Short Acting Short Acting –Salbutamol (ventolin)MDI, Neb,Oral,Inj. –Terbutaline (Bricanyl)MDI, Neb,Oral,Inj. Long Acting Long Acting –Salmetrol (Serevent)MDI

19. Non steroidal anti- inflammatory agents Sodium chromoglycate (Intal) Sodium chromoglycate (Intal) MDI, Spinhaler.

20. Corticosteroids Inhaled Inhaled –BeclomethasoneMDI, Neb (Becotide, Becloforte, Clenil A) –BudesonideMDI (Pulmicort) –FluticasoneMDI (Flixotide) Systemic Systemic –Prednisolone

21. Dosage of inhaled Corticosteroids Corticosteroids Low dose ug/day Medium dose ug/day High dose ug/day Beclomethasone200-400400-800>800 Budesonide200-400400-800>800 Fluticosone50-200200-400>400

22. Leukotrine Modifiers Leukotrine Receptor Antagonist Leukotrine Receptor Antagonist –Monteleukast(Singulair) –Zafrileukast(Accolate) Leukotrine Inhibitors Leukotrine Inhibitors –Zileuton

23. Slow Release Theophylline Theodur Theodur Theograd Theograd

24. Step-wise Approach Asthma Severity Days with sympt- oms Nights with symptoms FEV1/PEFR Control Medication Relief Medicat -ion Educa tion I Mild intermittent <3/wk <3/ mo >80 No medication SABA II Mild persistent >3/wk 3-4/ mo >80 Inhaled steroids (low dose) Inhaled steroids (low dose) LABA LABA Leukotrines modifiers Leukotrines modifiersSABA IIIModeratepersistentDaily >1/ wk 60-80 Inhaled steroids (medium dose) Inhaled steroids (medium dose) LABA LABA Leukotrines modifiers Leukotrines modifiers Sustained release theophylline Sustained release theophyllineSABA IVSeverepersistent Contin- ual sympt- oms frequent<60 Inhaled steroids (high dose) Inhaled steroids (high dose) LABA LABA Leukotrines modifiers Leukotrines modifiers Sustained release theophylline Sustained release theophylline Oral steroids Oral steroidsSABA

25. Rule of ‘3’ 1.Asthma symptoms or>3 times/wk need for bronchodilators 2.Awakes at night because>3 times/mth of asthma of asthma 3.Consumption of >3/year bronchodilator inhaler