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

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

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. Oct-15 Asthma Microscopic Pathology Obstructed Inflammed Bronchi

7. Before 10 Minutes After Allergen Challenge Bronchoconstriction

8. Oct-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 Attacks  Narrowing of airways occurs in response to inflammation or hyperresponsiveness to triggers, including:  Allergens  Infections  Diet/Medications  Strong Emotions  Exercise  Cold temperature  Exposure to irritants

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

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 : - PFT - Methacholine challenge test

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

19. What Types of Spirometers Are Available? SimplicitySpirotelSensaireSatelliteSpiroCard MicroPlusRenaissanceKoKoVitalograph 2120

20. Flow (l/s) (l/s) Volume (l) -2 0 -4 1 3 2 4 5 21345 -6 Spirometry: Flow-Volume Loops in Asthma

21. Peak Flow Meter

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

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

24. Combinations: Symbicort : budesonide + formoterol Seretide: fluticasone + salmeterol

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

27.  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

28. Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Systemic glucocorticosteroids Anti-IgE Inhaled glucocorticosteroids Leukotriene modifiers Systemic glucocorticosteroids Anti-IgE

29. Adults Patients with Asthma

31. 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

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

33. 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

34. summary  Asthma can be controlled but not cured  It can present in anybody at any age.  It produces recurrent attacks of symptoms of SOB, cough with or without wheeze  Between attacks people with asthma lead normal lives as anyone else  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