BRONCHIAL ASTHMA

Definition
Burden of Asthma Risk Factors

Mechanisms
Diagnosis and Classification Education and Delivery of Care

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role Chronic inflammation leads to an increase in airway hyperresponsiveness with recurrent episodes of wheezing, coughing, and shortness of breath

Widespread, variable, and often reversible airflow limitation

Risk Factors (for development of asthma)

INFLAMMATION
Airway Hyperresponsiveness Airflow Obstruction

Risk Factors (for exacerbations)

Symptoms

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

Host Factors

Environmental Factors
Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity

Genetic predisposition Atopy Airway hyperresponsiveness Gender Race/Ethnicity

Allergens Air Pollutants Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Consider asthma if any of the ff signs and symptoms are present:

frequent

episodes of wheezing more than once a

month

activity induced cough or wheeze

cough particularly at night during periods without viral infection absence of seasonal variation in wheeze

Consider asthma if any of the ff signs and symptoms are present: Symptoms occur or worsen in the presence of:

1. Aeroallergens 2. Animal furs and chemicals 3. Exercise 4. Pollen 5. Changes in temperature 6. Respiratory viral infections 7. Strong emotional expression 8. Tobacco

Consider asthma if any of the ff signs and symptoms are present: The patient also has eczema, hay fever or a family history of asthma or atopic disease Symptoms that persist after age 3 Childs colds take more than 10 days to clear up Symptoms improve when asthma medications are given

Controlled
Partly controlled Uncontrolled

Characteristic
Daytime symptoms (wheezing, cough, difficulty of breathing)

Controlled
None (can have attacks less than twice/week)

Partly controlled

uncontrolled

More than twice/ More than twice/ week (short periods week (minutesor minutes) hours and partially or fully relieved with rapid acting bronchodilators) Any (may cough, wheeze or have difficulty of breathing during exercise) Any (coughs or wakes up during sleep) > 2 days/ week Any (may cough, wheeze or have difficulty of breathing during exercise) Any (coughs or wakes up during sleep) > 2 days/ week

Limitation of activities

None (plays and runs)

Nocturnal symptoms or awakening Need for reliever or rescue treatment

None (no nocturnal coughing during sleep) 2 days/ week

Lung function measurements - provide an assessment of the severity, reversibility, and variability if airflow limitation Spirometry- preferred method of measuring airflow limitation and its reversibility Peak Expiratory Flow

An increase in FEV of 12% and 200ml after an administration of bronchodilator indicates reversible airflow limitation consistent with asthma Repeated testing is advised

Measurements are ideally compared to the patients own best measurement using his own peak flow meter An improvement in 60L/min (or 20% of prebronchodilator PEF) after inhalation of a bronchodilator or diurnal variation in PEF of more than 20%

Partnership between patients family and caretaker Avoidance of risk factor Assess, treat and monitor asthma control Recognize an asthma attack

Controlled On as needed rapid acting 2-agonist Continue as needed rapid-acting 2agonist

Partly controlled On as needed rapid acting 2-agonist Low dose inhaled glucocorticosteroid

uncontrolled Low dose inhaled glucocorticosteroid Double Low dose inhaled glucocorticosteroid

Leukotriene modifier Low dose inhaled glucocorticosteroid plus Leukotriene modifier

Drugs Beclamethasone dipropionate

Low daily dose (ug) 100

Budesonide MDI + spacer Budesonide nebulized Fluticasone propionate

200 500 100

Symptoms
Altered consciousness Oximetry on presentation Talks in no 94%

Mild

severe
Agitated, confused or drowsy < 90% words

sentences

Pulse rate

< 100 bpm

200bpm (0-3yrs old) 180 bpm (4-5 yrs old)

Likely to be present May be quiet

Central cyanosis Wheeze intensity

absent variable

Parameters
Breathless

Mild
Walking, can lie down Sentences

Moderate
Talking, difficulty feeding, prefers sitting Phrases

Severe
At rest stops feeding, hunched forward Words

Talks in

Alertness
RR Accessory muscles and retractions

May be agitated
Increased Usually not

Usually agitated
Increased Usually

Usually agitated
Often >30/m Usually

Parameters
Wheezes

Mild
Moderate and often only expiratory <100

Moderate
Loud

Severe
Loud

Pulse/min

100-120 Maybe present; 10-25mmHg Approximately 60-80%

>120 Often present; >25mmHg <60%

Pulsus paradoxus Absent; <10mmHg PEF after initial bronchodilator % predicted or personal best PaO2 SaO2 % Over 80%

Normal >95%

>60mmHg 91-95%

<60mmHg; possible cyanosis < 90%

Indication for immediate referral to hospital

Any of the ff: No response to 3 administrations of an inhaled short acting 2-agonist within 1 to 2 hours Tachypnea despite 3 administrations of an inhaled short acting 2-agonist Child is unable to speak or drink or breathless Cyanosis Subcostal retractions 92 % O2 saturation at room air Social environment that impairs delivery of acute treatment

Therapy
Supplemental O2 Short acting 2-agonist

Dose and administration

4lpm 2 puffs salbutamol by spacer or 2.5 mg salbutamol by neb every 20 min for 1st hr 2 puffs every 20 min for the first hour only Oral prednisolone(1-2 mg/kg x 5days) IV methylprednisolone (1-2mg/kg ) Consider in ICU: LD:6-10mg/kg; MD 1mg/kg no no

Ipratropium Systemic glucocorticosteroids Aminophylline Oral 2 agonist Long acting 2-agonist

Thank You...