Making a diagnosis

of
Asthma

Synonyms for asthma

allergy
allergic reaction
asthmatic bronchitis
bronchitis
wheezing disorder
atopy
breathing problem
bronchospasm

Mechanisms Underlying the
Definition of Asthma
Risk Factors
(for development of asthma)
Airway
Hyperresponsiveness Airflow Obstruction
Risk Factors
(for exacerbations)
Symptoms
INFLAMMATION
Host factors: Predispose individuals to,
or protect them from, developing asthma
Environmental factors: Influence
susceptibility to development of asthma in
predisposed individuals, precipitate
asthma exacerbations, and/or cause
symptoms to persist
Risk Factors for Asthma
Factors that Exacerbate Asthma
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Food, additives, drugs

Diagnosis: Why make it ?

The patient has alternatives
(if you dont, someone else will !)
Excellent prognosis, esp. in children
Treatment is so simple
Does one need a lot of tests?
Nothing usually, besides a
sharp history


What questions or statements can
suggest asthma?
Do you have a persistent cough ?
Do you wheeze or often feel breathless
while coughing ?
Do your symptoms worsen with climate
change, dust, smoke, strong smells,
perfumes, other allergens ?
What questions or statements
Do the symptoms get worse at night ?
Do you get chest tightness with the
cough ?
Does it all start with a cold ?
Do your colds often go down into the
chest ? (allergic rhinitis with asthma)

Other important questions.
Do your symptoms get worse after
extremes of happiness (laughter) or
sadness ? (emotional swings)
Do heavy meals or late nights worsen your
symptoms ? (GE reflux)
Are your symptoms worse at work than at
home ? (occupational asthma)
Importance of family history
Does anyone else in your family
suffer from any allergies ?

Ask about:
asthma
skin allergies
eczema
frequent colds
bronchitis
Trial of treatment is often the diagnosis
I got relief with this docs medicine.
Ask: which medicine?
(always check for bronchodilator or a short course of
oral steroid in an earlier prescription)
The Peak Flow Meter
like a thermometer for asthma
A must for all
asthmatics
Inexpensive clinic
instrument
Monitoring
Builds confidence in
treatment
One hard, fast blow
When do you need spirometry ?
Spirometry - should be done whenever
possible
To re-confirm the diagnosis
When in doubt
Bronchoprovocation tests if spirometry
normal (Histamine usually / methacholine)
Measuring Reversibility of Airflow
Obstruction
To measure the degree of reversibility of airflow
obstruction, perform spirometry/ PEF before and
10 to 15 minutes after administering a
bronchodilator by metered dose inhaler or
nebuliser
Beta
2
agonists (e.g. salbutamol) are generally
considered the benchmark bronchodilator
Dosage of bronchodilator
400 mcg salbutamol
OR
80 mcg anticholinergic

GOLD 2003
Concept of Minimal Persistent
Inflammation
Threshold level
for symptoms
0 , 1
1
1 0
1 0 0
0 2 4 6 8 1 0 1 2 M o n t h s
m
i
t
e

a
l
l
e
r
g
e
n

(

g
/
g

o
f

d
u
s
t
)


Minimal persistent
inflammation
Symptoms

inflammation
Ciprandi et al, J Allergy Clin I mmunol 1996
Allergic Rhinitis and Asthma


One airway ------ One disease
Take home messages
Asthma is a clinical diagnosis based largely
on good history-taking asking the right
questions
Often a trial of treatment is all that is
required, especially in children
PEFR- for diagnosis and monitoring
Spirometry to be done wherever possible
Differentiating from COPD is important
Drugs for the
management of asthma
Asthma disease:
spasm and swelling
Spasm needs a reliever
Bronchodilator
Swelling needs a preventer ( controller)
Anti-inflammatory
Two types of drugs:
reliever and preventer
Reliever ( quick relief )
Bronchodilator (beta
2
agonist)

Quickly relieves symptoms
(within 2-3 minutes)
Not for regular use
Reliever
Inhaled

Nebulised


Oral
Most of the time

For severe attacks;
administer at your
clinic/hospital


Rarely needed
Anti-inflammatory
Takes time to act (1-3 hours)
Prolonged effect (12-24 hours)
Only for regular use
(whether well or not well)
Preventer (controller)
Classification of asthma
medications
Quick Relief
Short-acting
2
-
agonist
Salbutamol
Terbutaline
Anticholinergics
Ipratropium Bromide
Short-acting
theophylline
Aminophylline

Adrenaline injections
Preventive ( controller )
Inhaled Corticosteroids
Beclomethasone
Budesonide
Fluticasone
Leukotriene modifiers
Montelukast
Long-acting
bronchodilators
Salmeterol (inhaled)
Formoterol (inhaled)
SA salbutamol (oral)
SR theophyllines (oral)

Preventer medication
Inhaled steroid
Long-acting b
2
agonists
Leukotriene Modifiers ( Montelukast )
Sustained-release Theophylline
Chronic oral steroid ( Prednisolone )
If your patient needs to use a
reliever medication every day, or
even more than three or four
times a week, preventive
medication must be added to the
treatment plan
GINA Workshop Report, 2003
Inhaled Corticosteroids are the
most potent and effective
anti-inflammatory medication
currently available for asthma
GINA Workshop Report, 2003
The story of asthma treatment
Normal
Regular
Inhaled
Steroid
Partly
Treated
Inflamed (untreated)
What is changing the lives of
our asthma patients today?
Inhaled steroid
Preventers ..
Inhaled corticosteroids
Budesonide/ beclomethasone/
fluticasone use any
Start (400-1000 mcg/day approx. in 2
divided doses)
Maintain for 3 months
Taper slowly
Safe for long-term use (years)
Why inhaled steroids early?
Most potent anti-inflammatory
medications for asthma
Prevent decline in lung function
Safer than other equally effective
treatments
Most cost-effective
Dose (inhaled steroids)

Beclomethasone
Budesonide
Fluticasone
Low dose
200-500mcg
200-600mcg
100-250mcg
Medium dose
500-1000mcg
600-1000mcg
250-500mcg
High dose
>1000mcg
>1000mcg
>500mcg
Stepping down steroids
Same dose for at least 3 months
Then, gradual stepwise reduction in
treatment (25% - 50% every 1 - 3 months)
Inhaled steroids :
safe even for children?
400 mcg/day (budesonide)
Over 9 years of continuous use
No growth retardation
Uncontrolled asthma causes growth
retardation
N Engl J Med 2000; 343:1064-69
Pregnancy and asthma
Dont x-ray (if possible)
All asthma medication is safe
Safety data on montelukast is extremely limited
Even oral corticosteroids are safe for exacerbations
Uncontrolled asthma during pregnancy is a serious risk
factor for foetal distress and anoxia
Thorax 2001 ; 56: 325-8
LABAs + steroids in a single inhaler
Synergistic effect - Corticosteroids increase beta
2
receptor
transcription and hence synthesis of beta
2
receptors and LABA
primes the inactive glucocorticoid receptor rendering the receptor
more sensitive to steroid dependant activation
Low doses of both drugs can be used, lesser side effects
Deposition of 2 drugs at same time and same site
Improves compliance
Ensures that both drugs are taken
More economical
Combination therapy
Formoterol ( fast relief and
sustained relief )
+
Budesonide ( twice or even once
daily use )
Dose: 1- 4 inhalations ( OD/BD )
Combination therapy
salmeterol (sustained relief )
+
fluticasone ( 3 times more potent than
budesonide )
Dose: 1- 2 inhalations (BD )

Leukotriene modifiers
Montelukast
Oral anti-inflammatory
Not as effective as inhaled steroid
First-line option for 2 to 5 yr. olds in mild
persistent asthma
All your regular bronchodilator users
Acts by blocking the cysteinyl LT receptor
thereby inhibiting the effects of LTD4
Theophylline
Sustained release for regular use
Inexpensive , but toxic
Not more than 600 mg per day usually
Weak bronchodilator, but anti-
inflammatory effects
Add-on drugs : ICS + ?
1. Long acting Beta

-agonist ( LABA )
2. Montelukast
3. SR Theophylline

What should you keep in
your clinic ?
Dry powder inhaler
Placebo dry powder capsules
Placebo MDI / Spacer / Baby Mask
Nebuliser ( for emergencies only )
Height measure
Peak flow meter
Education material (English / Hindi)

Then why asthma deaths ?
Preventable Factors
Underestimating severity by doctor
Underestimating severity by patient /
relative
Undertreatment with systemic steroids
Psychosocial (75%)
Inappropriate therapy (less ICS)