BRONCHIAL ASTHMA

Dr. Samson Bd Mokuntil

Definition

Asthma, irrespective of severity, is a chronic inflammatory disorder of the airways. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough particularly at night and in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.

PATHOGENESIS
The inflammatory features of asthma include: mucosal oedema and increasedvascular permeability denudation of airway epithelium collagen deposition beneath the basement membrane hypertrophy and hyperplasia of bronchialsmooth muscles and mucus glands inflammatory cell infiltration and activation of

cytokine production

Neutrophils mast cells Eosinophils T and B lymphocytes

Airway inflammation contributes to bronchial hyper-responsiveness, airflow limitation, respiratory symptoms and disease chronicity. Acute inflammation causes airway obstruction as a result of smooth muscle bronchospasm, mucosal oedema and mucus plug formation. Persistent chronic airway inflammation may result in airway remodeling which leads to irreversible bronchial obstruction. Atopy, the genetic predisposition for the development of an IgE-mediated response to common allergens, is the strongest identifiable predisposing factor for developing asthma.

DIAGNOSIS
Consider asthma if any of the following signs or symptoms are present: Wheezing high-pitched whistling sounds when breathing out (A normal chest examination does not exclude asthma). History of any of the following:

Note: Eczema, hay fever, or a family history of asthma or atopic diseases is often associated with asthma. Symptoms occur or worsen at night/early morning, awakening the patient

cough, worse particularly at night/early morning recurrent wheeze recurrent difficulty in breathing recurrent chest tightness

Symptoms occur or worsen in the presence of:

exercise respiratory tract infection Animals smoke (tobacco, wood) Pollen changes in temperature aerosol chemicals drugs (aspirin, beta blockers) dust mites (in mattress, pillows, upholstered furniture, carpets) strong emotional expression (laughing or crying hard)

Reversible and variable airflow limitation-as measured by a peak expiratory flow (PEF) meter in any of the following ways:

PEF increases more than 15% 15 to 20 minutes after inhaling a short-acting beta2 -agonist, or PEF varies more than 20% from morning measurement upon arising to measurement 12 hours later in patients who are taking a bronchodilator (more than 10% in patients who are not taking a bronchodilator), or PEF decreases more than 15% after 6 minutes of running or exercise cough, worse particularly at night/early morning

PEF Measurements
(i) During periods of well-being This allows measurement of the patients best PEF value which will provide the target for the doctor and the patient to aim for. Twice daily measurements (morning and evening) before any inhaled bronchodilator treatment will determine the diurnal variability of airway calibre. This is calculated as the range divided by the highest value and expressed as a percentage.

Good control of asthma means PEF variability is maintained at less than 10%

PEF (max) PEF (min) _______ %

x 100/PEF (max) =

(ii) During symptomatic episodes During an attack of asthma PEF fairly accurately measures the degree of bronchospasm. A PEF of less than 50% of normal or best suggests a very severe attack and a PEF of less than 30% suggests a life-threatening attack. When the best PEF value is not known, a single reading of less than 200 L/min usually indicates a severe attack.

GUIDELINES FOR THE MANAGEMENT OF ACUTE ASTHMA IN ADULTS

The

aims of management are:

To prevent death To relieve symptoms To restore the patients lung function to the best possible level as soon as possible To prevent early relapse

Assessment
The

severity of the attack should be assessed by:

History Physical examination PEF measurement

mild asthma attack

persistent cough increased chest tightness breathless when walking normal speech pulse rate < 100/min respiratory rate < 25 breaths/min moderate wheeze on auscultation, often end expiratory only PEF > 75% of predicted or best value SpO2> 95% (on room air)

moderately severe asthma attack

breathless

when talking talks in phrases pulse rate 100-120/min respiratory rate 25-30 breaths/min loud wheeze PEF between 50 to 75% of predicted or best value SpO2 91-95% (on room air)

very severe asthma attack

breathless

at rest talks in words pulse rate > 120/min respiratory rate > 30 breaths/min loud wheeze PEF < 50% predicted or best value SpO2 < 90% (on room air)

life-threatening asthma

central cyanosis feeble respiratory effort silent chest on auscultation bradycardia or hypotension exhaustion confusion or unconsciousness or convulsion PEF < 30% predicted or best value (or a single reading of < 100L/min). Arterial blood gas (ABG) tensions should be measured if a patient has any of the severe or lifethreatening features.

ANAGEMENT OF ACUTE ASTHMA IN AN OUTPATIENT SETTING

(i) INITIAL PEF > 75% (Mild acute asthma) Give the patients usual inhaled bronchodilator or nebulised bronchodilator. Multiple doses (5-20 puffs) of inhaled bronchodilator using a large volume spacer can be given in place of nebulised bronchodilator7072. Observe for 60 minutes. If the patient shows clinical improvement and PEF remains > 75%, discharge. Before discharge: review adequacy of usual treatment and step up if necessary according to guidelines for treatment of chronic persistent asthma ensure patient has enough supply of medications check and correct inhaler technique advise patient to return immediately if asthma worsens ascertain and address precipitating factors make sure that patient has a clinic follow-up appointment within 2 weeks

(ii) INITIAL PEF < 75% (this includes moderately severe to lifethreatening asthma) Patients with more severe degrees of acute asthma should be managed as follows:

a) High concentration oxygen (> 40%) b) High doses of inhaled beta2-agonist (salbutamol 5 mg or terbutaline 5 mg or fenoterol 5 mg) in combination with anticholinergic (ipratropium bromide 0.5 mg) should be administered via nebuliser driven by oxygen. If compressed air nebuliser is used, administration of supplemental oxygen should be continued. Alternatively, beta2-agonists may be given by multiple actuations of a pressurised aerosol inhaler into a large spacer device (2-5 mg, i.e. 20-50 puffs, five puffs at a time) preferably in combination with an anticholinergic. If there is poor response to inhaled bronchodilators, subcutaneous terbutaline or salbutamol 0.25-0.50 mg can be given.

c) Prednisolone tablets at 30-60 mg should be commenced immediately. If patient is unable to tolerate orally, intravenous hydrocortisone 200 mg stat or other forms of parenteral steroids should be given. High dose inhaled corticosteroids (2.4 mg budesonide daily in 4 divided doses) has been shown to achieve a relapse rate similar to 40 mg prednisone daily However, further studies are required to document the potential benefits of inhaled corticosteroids in acute asthma.

SUBSEQUENT MANAGEMENT IN THE WARD

Continue oxygen > 40% Intravenous hydrocortisone 100-200 mg 6 hourly or prednisolone 30-60 mg daily Nebulised beta2-agonist 2-4 hourly preferably in combination with anticholinergic (itmay be necessary to give nebulised beta2-agonist more frequently up to every 15 minutes) If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/hour); monitor blood levels (where facility is available) if aminophylline infusion is continued for more than 24 hours. Terbutaline or salbutamol infusion at 3-20 mcg/ min after an initial intravenous bolus dose of 250 mcg over 10 minutes can be given as an alternative In cases where response to the above treatment is inadequate, intravenous magnesium sulphate 2 g in 50 ml normal saline infused over 10-20 minutes may be given.

Monitoring the response to treatment

repeat measurement of PEF 15-30 minutes after starting treatment aim to maintain arterial oxygen saturation above 92% repeat arterial blood gas measurements if initial results are abnormal or if patient deteriorate monitor PEF at least 4 times daily throughout the hospital stay

Investigation
Serum

electrolytes, as hypokalaemia is a recognised complication of treatment with beta2-agonists and corticosteroids Electrocardiogram if indicated

 Transfer

patient to the intensive care unit or prepare to intubate if there is:

deteriorating PEF worsening hypoxaemia, or hypercapnia exhaustion or feeble respiration confusion or drowsiness coma or respiratory arrest

MANAGEMENT IN INTENSIVE CARE UNIT

continue with oxygen supplementation continue with intravenous hydrocortisone if the patient is mechanically ventilated, administer nebulised beta2- agonist with anticholinergic via the endotracheal tube. This can be given up to every 15-30 minutes Intravenous aminophylline infusion or terbutaline or salbutamol infusion should be continued and magnesium sulphate infusion may be added.

DISCHARGE PLAN FOR HOSPITALISED PATIENT

Before discharge, the patient should be:

started on inhaled steroids for at least 48 hours in addition to a short course of oral prednisolone and bronchodilators stable on the medications he is going to take outside the hospital for at least 24 hours having PEF of > 75% of predicted or best value and PEF diurnal variability of < 20% able to use the inhaler correctly and if necessary, alternative inhaler devices could be prescribed educated on the discharge medication, home peak flow monitoring and self management plan (for selected, motivated patients), and the importance of regular follow up given an early follow-up appointment within 2-4 w

MANAGEMENT OF CHRONIC ASTHMA

The

aims of management are

To abolish day and night symptoms of asthma To restore normal or best possible long term airway function To prevent most acute attacks To prevent mortality

Drug treatment

There are 3 major groups of medications to treat asthma

Anti-inflammatory medications Long-acting bronchodilators Short-acting bronchodilators

GINA CLASSIFICATION

EDUCATION OF PATIENT AND FAMILY

Patient education should include the following information:

Nature of asthma Preventive measures/avoidance of triggers Drugs used and their side-effects Proper technique of using inhaled drugs Peak flow monitoring Knowledge of the difference between relieving and preventive medications Recognition of features of worsening asthma (increase in brochodilator requirement, development of nocturnal symptoms, deteriorating peak flow rates) Self management plan The danger of non-prescribed self medication including certain traditional medicines

FOLLOW-UP AND MONITORING

Follow-up and monitoring include review of symptoms and measurement of lung function.

PEF monitoring at every visit along with review of symptoms helps in evaluating the patients response to therapy and adjusting treatment (step-up or step-down) accordingly. PEF consistently > 80% of the patient's personal best suggests good control. Regular visits (at 1 to 6 month interval as appropriate) are essential even after control of asthma is established. At each visit review the following questions:

1) Is the asthma management plan meeting the expected goals? 2) Is the patient using inhalers, spacers or peak flow meter correctly? 3) Is the patient compliant to the medication and avoiding triggers? 4) Does the patient have any concern?