1. ASTHMA

2. Asthma definition: “Asthma is a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyper responsiveness. It presents with recurrent episodes of wheeze, cough, shortness of breath, and chest tightness.”

3. Clinical features that increase the probability of asthma More than one of the following symptoms: Wheeze, cough, Difficulty in Breathing, chest tightness, particularly if symptoms: – are frequent and recurrent – are worse at night and in the early morning – occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold, damp air, or with emotions/laughter Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy

4. Clinical features that lower the probability of asthma Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal peak expiratory flow (PEF) or spirometry when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis

5. Causes of Asthma The development of asthma appears to involve the interplay between host factors (particularly genetics) and environmental exposures that occur at a crucial time in the development of the immune system. Innate immunity: Imbalance between Th1-type and Th2- type cytokine responses in early life. The immune response will down regulate the Th1 immune response that fights infection and instead will be dominated by Th2 cells, leading to the expression of allergic diseases and asthma. This is known as the “hygiene hypothesis,” which postulates that certain infections early in life, exposure to other children, less frequent use of antibiotics, and “country living” is associated with a Th1 response and lower incidence of asthma, whereas the absence of these factors is associated with a persistent Th2 response and higher rates of asthma.

6. Genetics: Asthma has an inheritable component, but the genetics involved remain complex. Environmental factors: Two major factors are the most important in the development, persistence, and possibly the severity of asthma:  airborne allergens (particularly sensitization and exposure to house-dust mite and Alternaria)  viral respiratory infections (including respiratory syncytial virus [RSV] and rhinovirus). Other environmental factors are under study:  tobacco smoke (exposure in utero is associated with an increased risk of wheezing, but it is not certain this is linked to subsequent development of asthma),  air pollution (ozone and particular matter) and  diet (obesity or low intake of antioxidants and omega-3 fatty acids).

7. Mechanisms: Asthma Inflammation

9. Asthma Inflammation: Cells and Mediators

12. Early Childhood Risk Factors Parental Asthma Allergy – Atopic dermatitis – Allergic rhinitis – Food allergy – Inhalant allergen sensitization – Food allergen sensitization

13. Precipitating and/or aggravating factors Viral respiratory infections Environmental allergens, indoor (e.g., mold, house-dust mite, cockroach, animal dander or secretory products) and outdoor (e.g., pollen) Characteristics of home including age, location, cooling and heating system, wood-burning stove, humidifier, carpeting over concrete, presence of molds or mildew, presense of pets with fur or hair, characteristics of rooms where patient spends time (e.g., bedroom and living room with attention to bedding, floor covering, stuffed furniture) Smoking (patient and others in home or daycare) Exercise Occupational chemicals or allergens

14. Environmental change (e.g., moving to new home; going on vacation; and/or alterations in workplace, work processes, or materials used) Irritants (e.g., tobacco smoke, strong odors, air pollutants, occupational chemicals, dusts and particulates, vapors, gases, and aerosols) Emotions (e.g., fear, anger, frustration, hard crying or laughing) Stress (e.g., fear, anger, frustration) Drugs (e.g., aspirin; and other nonsteroidal anti-inflammatory drugs, beta- blockers including eye drops, others) Food, food additives, and preservatives (e.g., sulfites) Changes in weather, exposure to cold air Endocrine factors (e.g., menses, pregnancy, thyroid disease) Comorbid conditions (e.g. sinusitis, rhinitis,GERD )

15. Classifying Severity and Initiating Treatment

16. CLINICAL FEATURES Symptoms: Intermittent dry cough Expiratory wheezing Shortness of breath Chest tightness Chest pain Fatigue Difficulty keeping up with peers in physical activities Signs: Expiratory wheezing Prolonged expiratory phase Decreased breath sounds Crackles/ rales Accessory muscle use Nasal flaring Absence of wheezing in severe cases Pulses paradoxus

17. Spirometry: Feasible in children >6 years of age Monitoring Asthma and efficacy of treatment Measures FVC, FEV 1 and FEV1/FVC Ratio Normal values for children available on the basis of height, gender and ethnicity. Airflow Limitation:  Low FEV1  FEV1/ FVC ratio < 0.80 Bronchodilator response to β-agonist:  Improvement in FEV1 ≥ 12% Exercise challenge:  Worsening of FEV1 ≥ 15% Peak expiratory flow rate: It is highly suggestive of asthma when: >15% increase in PEFR after inhaled short acting β2 agonist >15% decrease in PEFR after exercise Diurnal variation > 10% in children not on bronchodilator X-ray : Often normal, sometimes Hyperinflation

20. DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA

21. APPROACH Detailed history Symptoms Cough, Wheezing, Shortness of breath, Chest tightness, Sputum production Pattern of symptoms Perennial, seasonal, or both Continual, episodic, or both Onset, duration, frequency (number of days or nights, per week or month) Diurnal variations, especially nocturnal and on awakening in early morning Family history History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps in close relatives

22. Social history Daycare, workplace, and school characteristics that may interfere with adherence Social factors that interfere with adherence, such as substance abuse Social support/social networks Level of education completed Employment History of exacerbations Usual prodromal signs and symptoms Rapidity of onset Duration Frequency Severity (need for urgent care, hospitalization, intensive care unit (ICU) admission.) Life-threatening exacerbations (e.g., intubation, intensive care unit admission) Number and severity of exacerbations in the past year. Usual patterns and management (what works?)

23. Impact of asthma on patient and family Episodes of unscheduled care (emergency department (ED), urgent care, hospitalization) Number of days missed from school/work Limitation of activity, especially sports and strenuous work History of nocturnal awakening Effect on growth, development, behavior, school or work performance, and lifestyle Impact on family routines, activities, or dynamics Economic impact

24. Assessment of patient’s and family’s perceptions of disease Patient’s, parent’s, and spouse’s or partner’s knowledge of asthma and belief in the chronicity of asthma and in the efficacy of treatment Patient’s perception and beliefs regarding use and longterm effects of medications Ability of patient and parents, spouse, or partner to cope with disease Level of family support and patient’s and parents’, spouse’s, or partner’s capacity to recognize severity of an exacerbation Economic resources Sociocultural beliefs

25. Asthma Management and Prevention Program: Five Components 1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma 4. Manage Asthma Exacerbations 5. Special Considerations

26. 1. Develop Patient/Doctor Partnership Guidelines on asthma management should be available for local use by local asthma planning teams Clear communication between health care professionals and asthma patients is key Educate continually Include the family Provide information about asthma Provide training on self-management skills Emphasize a partnership among health care providers, the patient, and the patient’s family

28. 2. Identify and Reduce Exposure to Risk Factors Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs. Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma development, especially in children and young infants Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised

29. 3. Assess, Treat and Monitor Asthma The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional. The focus on asthma control is important because: Attainment of control correlates with a better quality of life, and reduction in health care use Determine the initial level of control to implement treatment (assess patient impairment) Maintain control once treatment has been implemented (assess patient risk)

30. Levels of Asthma Control (Assess patient impairment) Levels of Asthma Control (Assess patient impairment)

31. Assess Patient Risk Features that are associated with increased risk of adverse events in the future include: Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV 1, exposure to cigarette smoke, high dose medications

32. Depending on level of asthma control, the patient is assigned to one of five treatment steps Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control A stepwise approach to pharmacological therapy is recommended The aim is to accomplish the goals of therapy with the least possible medication Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

33. The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability of the various forms of asthma treatment Economic considerations Cultural preferences and differing health care systems

34. Medications in Asthma Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β 2 -agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE Reliever Medications Rapid-acting inhaled β 2 -agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral β 2 -agonists

35. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose(  g) > 5 y Age 5 y Age < 5 y Medium Daily Dose (  g) > 5 y Age 5 y Age < 5 y High Daily Dose (  g) > 5 y Age 5 y Age < 5 y Beclomethasone200-500 100-200 >500-1000 >200-400 >1000 >400 Budesonide200-600 100-200 600-1000 >200-400>1000 >400 Budesonide-Neb Inhalation Suspension 250-500 500-1000 >1000 Ciclesonide 80 – 160 80-160 >160-320 >160-320>320-1280 >320 Flunisolide500-1000 500-750>1000-2000 >750-1250 >2000 >1250 Fluticasone100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate200-400 100-200 > 400-800 >200-400>800-1200 >400 Triamcinolone acetonide400-1000 400-800>1000-2000 >800-1200>2000 >1200

36. Allergen-specific Immunotherapy Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis The role of specific immunotherapy in asthma is limited Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma Perform only by trained physician

37. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE STEP 1 STEP 1 STEP 2 STEP 2 STEP 3 STEP 3 STEP 4 STEP 4 STEP 5 STEP 5 REDUCE INCREASE

39. Treating to Maintain Asthma Control When control as been achieved, ongoing monitoring is essential to: - maintain control - establish lowest step/dose treatment Asthma control should be monitored by the health care professional and by the patient

40. Stepping down treatment when asthma is controlled When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals. When controlled on low-dose inhaled glucocorticosteroids: switch to once- daily dosing When controlled on combination inhaled glucocorticosteroids and long- acting inhaled β 2 -agonist: reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β 2 -agonist If control is maintained: reduce to low-dose inhaled glucocorticosteroids and stop long-acting β 2 -agonist

41. Stepping up treatment in response to loss of control Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief. Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy Use of a combination rapid and long-acting inhaled β 2 -agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended

43. Component 4: Manage Asthma Exacerbations Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV 1 or PEF) Severe exacerbations are potentially life-threatening and treatment requires close supervision Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the particular patient Availability of medications Emergency facilities

44. Primary therapies for exacerbations: Repetitive administration of rapid-acting inhaled β 2 -agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

45. 5.Special considerations Special considerations are required to manage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma

46. STATUS ASTHAMATICUS Status asthmaticus is the condition of a patient in progressive respiratory failure due to asthma, in whom conventional forms of therapy have failed

47. Status Asthamaticus Assessment Findings consistent with impending respiratory failure: Altered level of consciousness Inability to speak Absent breath sounds Central cyanosis Diaphoresis Inability to lie down Marked pulsus paradoxus

48. Clinical Asthma Score

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