Beruflich Dokumente
Kultur Dokumente
Pathophysiology andmanagement
DrDeepakAggarwal
MD,FCCP
Asst.Professor
Pulmonarymedicine
WhatisAsthma..Definition(GINA)
Asthmais
Achronicinflammatorydisorderoftheairwaysin
whichmanycellsandcellularelementsplayarole.
Thechronicinflammationisassociatedwithairway
hyperresponsiveness thatleadstorecurrentepisodes
ofwheezing,breathlessness,chesttightnessand
coughingparticularlyatnightorearlymorning.
Theseepisodesareusuallyassociatedwithwidespread,
butvariableairflowobstructionwithinthelungthatis
oftenreversibleeitherspontaneouslyorwith
treatment
Causes/Riskfactors
GENETICSUSCEPTIBILITYAND ENVIRONMENTALRISK
GENEENVIRONMENTINTERACTIONS FACTORS
Perinatal Factors
IndoorandOutdoorAllergens
SmokingandEnvironmentalTobacco
Smoke
OtherPollutants
Race/EthnicityandSocioeconomic
Status
Obesity
RespiratoryIllnesses
HowAsthmadevelops..
PATHOGENESIS
PATHOGENESIS
ASTHMA PATHOPHYSIOLOGY
Asthma
Geneticpredisposition Inflammationunderliesdisease
processes
Intrinsicvulnerability Clinicalsymptomsalsovaryby
Atopy/allergy Phenotypevariesbyindividual individualandovertime
andovertime
PATHOLOGY
Asthma:Pathologicalchanges
Pathologyandconsequences
COPD Asthma
Neutrophils Eosinophils
CD4+ T-lymphocytes CD8+ T-lymphocytes
Noairway Wheezy Airway
hyperresponsiveness bronchitis10% hyperresponsiveness
Lessbronchodilator Bronchodilator
response response
Limitedsteroid Steroid
response response
incompletely Completely
irreversible reversible
PhysiologicDifferences
Asthma COPD
NormalDLCO AbnormalDLCO
Normallungvolume Hyperinflation
Normalelasticrecoil Decreasedelasticrecoil
SciurbaFC,CHEST2004;117S124S
DiseasePathology Asthma COPD
Reversibleairflowobstruction +++ +
Airwayinflammation ++ + ++
Mucushypersecretion + +++
Gobletcellmetaplasia + ++
Impairedmucusclearance ++ ++
Epithelialdamage ++
Alveolardestruction ++
Smoothmusclehypertrophy ++
Basementmembranethickening +++
AsthmaClassicpresentation
Intermittentepisodic,acute/subacute onset
Breathlessness/chesttightnessusuallywith
wheeze
Coughnocturnalorearlymorning.
Diurnalandseasonalvariation
Historyofatopy,familyhistory
Polyphonicwheeze,prolongedexpiration
However,theexaminationcanbenormal.
Differentialdiagnosis
DIAGNOSIS
Cough, wheezing
and
Breathlessness
SUSPECT OTHER
MANAGE AS
Sputum for AFB (x3) DIAGNOSES OR
ASTHMA COMPLICATIONS
TUBERCULOSIS MANAGE AS
(Refer to RNTCP) COPD 18
Key indicators for considering a
diagnosis of asthma
Typical history
Intermittent symptoms (reversible)
Association of symptoms to weather changes, dust,
smoke, exercise, viral infection, animals with fur or feathers,
house-dust mites, mold, pollen, strong emotional expression
(laughing or crying hard), airborne chemicals or dust
Diurnal variation
Family history
Presence of atopy, allergic rhinitis, skin allergies
RoutineInvestigations
Hemogram includingeosinophil count
Bloodgasanalysis
Xraychest
Serumelectrolytes(Mg,Na,K)
Spirometry
Othertesttoruleoutspecificdiseases
Spirometry
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GINALevelsofAsthmaControl
Partly controlled
Characteristic Controlled Uncontrolled
(Any present in any week)
Preventfutureattacks
Longtermcontrol
Preventairway
remodeling
WhatAreRelievers?
Rescuemedicationstotreat
acutebronchospasm
Quickreliefofsymptoms
Usedduringacuteattacks
Actionusuallylasts46hrs
Methods of Medication Delivery
Metered-dose inhaler (MDI)
Spacer/holding chamber/face mask
Dry-powder inhaler (DPI)
Nebulizer
Oral Medication
Tablets, Liquids
Intravenous Medication
IV Corticosteroids, IV Aminophylline
CONTROLLERS
Inhaled Corticosteroids
Benefits
Reduced airway inflammation through topical activity
Decreases airway hyper-responsiveness.
Improve lung function and quality of life
Reduce the frequency of exacerbations
Reduced use of quick-relief medicine
Inhaled
Beclomethasone
Fluticasone
Triamcinolone
Budesonide
Flunisolide
Anti-inflammatory Effect of Glucocorticoid
EstimatedComparativeDailyDosagesfor
AdultsofInhaledCorticosteroids
Drug Low Dose Medium Dose High Dose
Step 2 Step 3 Step 4
Beclomethasone 1-3 puffs 3-6 puffs >6 puffs
80 - 240 mcg 240 - 480 mcg > 480 mcg
Fluticasone 2-6 puffs (44) 2-6 puffs (110) > 6 puffs (110)
88-264 mcg 264-660 mcg > 660 mcg
Advantages
Blunt exercise induced symptoms for longer time
Decrease nocturnal symptoms
Improve quality of life
5-Lipoxygenase inhibitors
Zileuton Four times daily
Many drug interactions
AddonControllers
Leukotriene Modifiers
Montelukast
Improveslungfunctionandasthmacontrol
Mayprotectagainstexerciseinducedbronchoconstriction
Notaseffectiveasinhaledcorticosteroids
No food restrictions
RELIEVERS
Short-Acting Beta -agonist
Salbutamol
Terbutaline
levosalbutamol
RELIEVERS
Short-Acting Beta2-Agonists
Most effective medication for relief of acute
bronchospasm
Increased need for these medications indicates
uncontrolled asthma (and inflammation)
Use as needed as regular use
May lower effectiveness
May increase airway hyperresponsiveness
RELIEVERS
Short-Acting Beta2-Agonists
Side Effects:
Increased Heart Rate
Palpitations
Nervousness
Sleeplessness
Headache
Tremor
UnwantedBetaAdrenergicEffects
Hypokalemia(Kshiftintomuscletissue)
Hyperglycemia(glycogenolysis)
Hypoxia(pulmonaryvasodilationcausing
increasedventilation/perfusion
mismatch)
OralSteroidShortCourse
Prednisone3040mgx1014days
foracuteexacerbationofAsthma
noweaningofdoseunlesslong
termuse
Step 1 Treatment for Adults and
Children > 5: Mild Intermittent
Controller Daily
Notneeded
Shortactinginhaledbeta2agonist
Increasinguse,orusemorethan
2x/week,mayindicateneedfor
longtermcontroltherapy
Alternatives
Increaseinhaledcorticosteroidstomedium
doserange
OR
Lowtomediumdoseinhaledcorticosteroid
(mediumdose)andeitherleukotriene
modifierortheophylline
Step 3 Treatment for Adults and
Children > 5: Moderate Persistent
(patients with recurring severe exacerbations) STEP4
Controller
Mediumdoseinhaledcorticosteroid
(mediumdose)andlongactingbeta2
agonist
Alternatives
Mediumdoseinhaledcorticosteroid
(mediumdose)andeitherleukotriene
modifierortheophylline
Highdoseinhaledcorticosteroid
Considerreferraltoaspecialist
Step 4 Treatment for Adults and
Children > 5: Severe Persistent
STEP 5
Controller Daily
HighdoseinhaledcorticosteroidAND
Longactinginhaledbeta2agonist
AND,ifneeded,
Addleukotriene antagonists&
theophylline
Corticosteroidtablets
MonitorAsthmaControl
Treating to Maintain Asthma Control
Steppingdowntreatmentwhenasthmaiscontrolled
Whencontrolledonmedium tohighdoseinhaled
glucocorticosteroids:50%dosereductionat3
monthintervals(EvidenceB)
Whencontrolledonlowdoseinhaled
glucocorticosteroids:switchtooncedailydosing
(EvidenceA)
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Treating to Maintain Asthma Control
Steppinguptreatmentinresponsetolossofcontrol
Rapidonset,shortactingorlongactinginhaled2
agonistbronchodilatorsprovidetemporaryrelief
Needforrepeateddosingovermorethanone/two
dayssignalsneedforpossibleincreaseincontroller
therapy
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Managingthewellcontrolledpatient
Assoonasgoodcontrol:
Reduceoralsteroidsfirst,thenstop
Reducerelieversbeforecontrollers
Whengoodcontrolfor3+months:
Reduceinhaledsteroids
Therapytoavoid!
Sedatives&hypnotics
Coughsyrups
Antihistamines
Immunosuppressivedrugs
Immunotherapy
Maintenanceoralprednisone>10mg/day
Managingpartly/uncontrolledasthma
Checktheinhalertechnique
Checkadherenceandunderstandingof
medication
Consideraggravationby:
Exposuretotriggers/allergensathomeorwork
Comorbidconditions:GIreflux,rhinitis/sinusitis,
cardiacproblem
Medications:Betablockers,NSAIDs,Aspirin
The Asthma Action Plan
Helps patients/caregivers manage asthma
Uses Peak Flows
Spells out medication instructions
Nebulizers
pMDIs
AdvantagesDisadvantages
Smallandportabledifficulttolearntechnique
Unsuitableforchildren<56
QuicktouseUnsuitablefortheelderly,
Coldjetmayirritatethroat
Limitedamountofdrug
deliveredperpuff
Spacers and Holding
Chambers
Aspacerdeviceenhancesdeliveryby
decreasingthevelocityoftheparticlesand
reducingthenumberoflargeparticles,
allowingsmallerparticlesofdrugtobeinhaled.
A spacer device with a one-way valve, i.e., holding chamber,
eliminates the need for the patient to coordinate actuation
with inhalation and optimizes drug delivery.
Generallyeasiertouse
Aminimalinspiratory flowrateisnecessarytoinhale
fromaDPI;difficultforsomeptstouseduringan
exacerbation
MoreecologicalthanMDIs
Storagemaybedifficultinhumidclimates
Nebulizer
Advantages Disadvantages
NoCoordinationrequired Cumbersome
Canbeusedforallages Expensive
Effectiveinsevereasthma Noisy
Treatment takestime
Whichinhalationdeviceforwhich
patient?
InfantsandchildrenpMDI+spacer,nebulizer
up5y/o
Children59y/opMDI+spacer,nebulizer,DPI
CompetentolderpMDI,DPI
childrenandadults
IncompetentolderpMDI+spacer,nebulizer
children/adults
KeyMessages
Asthmaiscommonandcanstartatanyage
Asthmacanbeeffectivelycontrolled
Effectiveasthmamanagementprogramsinclude
education,objectivemeasuresoflungfunction,
environmentalcontrol,andpharmacologictherapy.
Astepwiseapproachtopharmacologictherapyis
recommended.
Theaimistoaccomplishthegoalsoftherapywiththe
leastpossiblemedication.
Thankyou