Asthma the hero of saving the life and the vearagggs.pptx

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1. Department of Internal medicine F ederal state educational institution of higher education « Bashkir State medical University Ministry of Health of the Russian Federation » Lecture for students Specialty – General Medicine 31.05.03 Discipline –Faculty therapy Speaker : S.V . Piatnitskaia «ASTHMA » Head of department: associate professor, p.h.d . A.V.Tyrin

2. OVERVIEW 1.Definition 2.Epidemiology 3 Risk factors 4.Pathogenesis 5.Classification 6.The clinical sings 7.Diagnosis and differentiated diagnosis 8.Treatment 9.Prevention

3. Definition by GINA The Global Initiative for Asthma (GINA) was established by the World Health Organization and the US National Heart Lung and Blood institute in 1993 to improve asthma awareness, prevention, and management worldwide. https://ginasthma.org /

4. Russian Respiratory Society https://spulmo.ru /

5. Definition A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyper‐responsiveness that leads to recurrent episodes of wheezing , breathlessness, chest tightness and coughing particularly at night or early morning . These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

6. Epidemiology Most common chronic disease currently affecting appx. 300 million people worldwide 10 ‐ 12% of adults 15 % of children boys than girls(2:1) women than men attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted

7. Risk factors Atopy – Major risk factor – The body’s predisposition to develop an antibody ( IgE ) in response to exposure to environmental allergens - IgE can be measured in the blood – Includes allergic rhinitis, asthma, hay fever, and eczema

8. С auses / Risk factors

9. Some allergens may cause asthma

10. Trigger-factors Provoke bronchospasm 1.Allergens 2.Exercise and hyperventilation 3.Viral infection 4.Emotional stress 5.Cold air 6.Aspirin,b-blockers

11. Pathogenesis Asthma inflammation : Cell and mediators

12. Pathogenesis Asthma inflammation : Cell and mediators

13. Mechanism of bronchspasm

14. R eversible components of bronchial obstruction 1. Mucosal edema 2. Hypersecretion 3. Spasm smooth

15. Irreversible components of bronchial obstruction 1. Expiratory collapse of small bronchi due to developing emphysema 2. Tracheobronchial dyskinesia 3. Obliteration of the bronchial lumen due to peribronchial fibrosis

16. Summary I nflammation Remodeling • Inflammation • Airway Hypersecretion • Subepithelial fibrosis

17. Aspirin Induced Asthma Aspirin-induced asthma is a type of asthma triggered by aspirin. It is also triggered by other non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Aspirin-induced asthma is also called aspirin-exacerbated respiratory disease (AERD)

18. Asthma Sensitivity to aspirin and other NSAIDs Sinus infection with nasal polyps Aspirin Induced Asthma

19. Aspirin and other NSAIDs work by blocking an enzyme called COX-1. This reduces inflammation and relieves pain. But blocking COX-1 decreases anti-inflammatory prostaglandins. It also increases pro-inflammatory leukotrienes. This can lead to acute asthma and allergy-like reactions. Aspirin Induced Asthma

20. Allergic asthma Non allergic asthma Asthma with late onset Asthma in obese patients Classification according phenotype

21. Classification

22. Classification

23. 1. Emphysema 2. Pneumosclerosis 3 .Spontaneous pneumothorax 4 . L ung atelectasis 5 .Cor pulmonale 6 . Asthmatic status!!! 7.Respiratory failure Complications of Asthma

24. Sample of Diagnosis Allergic asthma, moderate stage, controlled course. Allergic rhinitis, mild. Sensitization to house dust mites allergens. Respiratory failure 1. Non-allergic asthma, moderate, insufficiently controlled. Recurrent polyposis sinusitis. Intolerance to NSAIDs ("aspirin triad"). Non-allergic asthma, moderate uncontrolled course, severe exacerbation. Asthmatic status, compensated stage. Obesity II.

25. Clinical presentation of Asthma 1. Wheezing (a whistling sound as air is forcibly expelled ) 2. Difficulty breathing (expiratory)! 3. Chest tightness 4. A persistent cough ( Cough variant asthma (CVA) is a form of asthma, which presents solely with cough)

26. In “classic asthma” variable airflow obstruction typically leads to symptoms such as wheeze, dyspnea and cough . CVA is a subtype of asthma that usually presents solely with cough without any other symptoms such as dyspnea or wheezing . In cough-predominant asthma cough is the most predominant symptom but other symptoms are also present such as dyspnea and/or wheeze. Cough variant asthma ( CVA)

27. Symptoms of a severe asthma attack can include: 1. Ex peratory shortness of breath 2. Chest tightness 3. R apid pulse 4. Sweating 5. Flared nostrils and pursed lips 6.N eed to sit upright 7.B luish discoloration of the lips and fingernails Clinical presentation of Asthma

28. Inspection finding Pursed lips Tripod position- siting forward and bracing arms on table

29. Inspection finding Warm (central cyanosis) Barrel-like chest Change in nails ("watch glasses") and thickening of the terminal phalanges ("drumsticks" of the hands and feet)

30. Diagnostic proc e dure for asthma

31. Spirography is Gold standard for diagnosis It is obligatory to determine: vital capacity of the lungs (VC), forced vital capacity of the lungs (FVC), forced expiratory volume in 1 second (FEV1), the most indicative is FEV1 / FVC ( Tiffno's ratio). A normal ratio is 70% to 80%.

32. Bronchodilator test To study the reversibility of obstruction - a test with inhaled bronchodilators, their effect on flow-volume curve readings, mainly per forced expiratory volume in 1 second (FEV1) 400 μ g (4 doses) of a short-acting beta2-agonist (salbutamol, fenoterol ) through a dosing balloon with a spacer, assessment of FEV1 after 15-30 minutes 80 mcg (4 doses) short-acting anticholinergic (ipratropium bromide)

33. Spirometry should be done – at the time of initial assessment – after treatment is initiated and symptoms and peak expiratory flow (PEF) have been stabilized – at least every 1 to 2 years to assess the maintenance of airway function

34. Significant bronchodilatory response should exceed spontaneous variability, as well as the response to bronchodilators in healthy individuals . Therefore, the increase in FEV1 ≥ 12% of the due and ≥ 200 ml is recognized as a marker of a positive bronchodilatory response; it means that bronchial obstruction is reversible .

35. Spirography Curve

36. Spirography с urve after bronchodilator test

37. Asthma is a chronic inflammatory disease of the airways which develops under the allergens influence, associates with bronchial hyperresponsiveness and reversible obstruction and manifests with attacks of dyspnea, breathlessness, cough, wheezing, chest tightness and Wheezing more expressed at breathing-out. Differentiated diagnosis COPD and Asthma

38. Differentiated diagnosis COPD and Asthma

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40. Differentiated diagnosis COPD and Asthma

41. Key indicators for considering a diagnosis of asthma • 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 • Presence of atopy , allergic rhinitis , skin allergies • Family history

42. Goals of Asthma Therapy 1.Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations 2. Maintain (near‐) “normal” pulmonary function 3. Maintain normal activity levels (including exercise and other physical activity) 4.Provide optimal pharmacotherapy with minimal or no adverse effects 5. Prevent asthma mortality

43. Component 1: Develop Patient/Doctor Partnership 1.Educate continually, i nclude the family 2 . Provide information about asthma 3. Provide training on self-management skills 4. Emphasize a partnership among health care providers , the patient, and the patient’s family

44. Component 2: Identify and Reduce Exposure to Risk Factors 1. Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. 2. Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs . 3. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.

45. Component 2: Identify and Reduce Exposure to Risk Factors 1. Reduce exposure to indoor allergens 2. Avoid tobacco smoke 3. Avoid vehicle emission 4. Identify irritants in the workplace 5. Explore role of infections on asthma development , especially in children and young infants

46. Component 3: Assess, Treat and Monitor Asthma Asthma drug classification

47. Methods of Medication Delivery 1. Metered-dose inhaler (MDI) 2. Spacer/holding chamber/face mask 3. Dry-powder inhaler (DPI) 4. Nebulizer 5. Oral Medication ( Tablets , Liquids ) 6. Intravenous Medication ( Corticosteroids, Euphylline )

48. Inhaled Corticosteroids Treatment of choice for long-term control of persistent asthma Benefits 1. Reduced airway inflammation through topical activity 2. Decreases airway hyper-responsiveness. 3. Improve lung function and quality of life 4. Reduce the frequency of exacerbations 5. Reduced use of quick-relief medicine

49. Inhaled Corticosteroids

50. Combination Inhaled Corticosteroid and Bronchodilator Inhalers Symbicort ( formoterol and bedesonide ) Advair ( salmeterol and fluticasone)

51. Corticosteroid Side Effects

52. Bronchodilators The main groups of drugs: Anticholinergics B2 agonists Theophylline Combined drugs The choice of therapy depends on the availability of the drug, the individual "response" of the patient, taking into account the reduction of symptoms and the manifestation of side effects .

53. Bronchodilate by long-term stimulation of beta2 receptors Advantages 1. Blunt exercise induced symptoms for longer time 2. Decrease nocturnal symptoms 3. Improve quality of life 4. Combination therapy beneficial when added to inhaled corticosteroids 5. Decrease the need to increase inhaled corticosteroid dose by dose Bronchodilators

54. Mechanism action of beta2 agonist Relax bronchial smooth muscle (stimulation beta 2 R in bronchi) 1. Inhibit mediator release from mast cells , eosinophils, macrophages 2. Decrease mucous secretion 3. Increase mucociliary transport 4. Inhibit bronchial oedema 5. Inhibit cholinergic transmisssion 6. Decrease airway hyper responsivenes

55. Short-Acting Beta 2-Agonists Most effective medication for relief of acute bronchospasm Preferably use inhaled rather than oral preparations Increased need for these medications indicates uncontrolled asthma (and inflammation) Regularly scheduled use not generally recommended – use “as needed ” May lower effectiveness May increase airway hyperresponsiveness

56. Side Effects: 1. Increased Heart Rate 2. Palpitations 3. Nervousness 4. Sleeplessness 5. Headache 6. Tremor Short-Acting Beta 2-Agonists

57. Bronchodilators

58. 1. Cysteinyl Leukotriene Receptor Antagonists Montelukast – Once a day in PM Zafirlukast – Twice daily – Empty Stomach 2. 5-Lipoxygenase inhibitors Zileuton – Four times daily Leukotriene Modifiers

59. Montelukast 1. Improves lung function and asthma control 2. May protect against exercise induced bronchoconstriction 3. Improves lung function when added to inhaled corticosteroids 5. 4 mg, 5 mg chewable and 10 mg tablet 6. Once daily dosing (evening) 7. Pediatric indication > 1 year 8. No food restrictions Leukotriene Modifiers

60. Therapy to avoid!

61. Step 1 Treatment for Adults and Children > 5: Mild Intermittent

62. Step 2 Treatment for Adults and Children > 5: Mild Persistent

63. Step 3 Treatment for Adults and Children > 5: Moderate Persistent

64. Step 3 Treatment for Adults and Children > 5: Moderate Persistent ( patients with recurring severe exacerbations)

65. Step 4 Treatment for Adults and Children > 5:Severe Persistent

66. Monitor Asthma Control

67. Avoid Smoke of Any Type Physical activity Vaccination against influenza and against pneumococcal infection, Covid-19 4. Allergy-Proof Home Asthma Prevention

68. Thank you for your attention !