Bronchial Asthma by Dr. Sookun Rajeev Kumar

Bronchial Asthma

1. Dr. Sookun Rajeev K (MD) Dept of General Medicine Anna Medical College BRONCHIAL ASTHMA

2. Definition: Asthma is a disease characterised by: Chronic Airway Inflammation Increased Airway Responsiveness Airways Obstruction Variable over Short Periods of Time Reversible with Treatment

3. Allergic asthma (extrinsic) Non-allergic asthma (intrinsic) Cough variant asthma Occupational asthma Exercise induced asthma Medication induced asthma Nocturnal asthma Types Of Asthma

4. Pathology

5. Pathophysiology Acute Asthma Airway Obstruction V/Q mismatch Hypoxemia Ventilation PaCO2 / pH & Fatigue Ventilation PaCO2/ pH

6. Etiology Of Asthma Genetic factors Environmental factors House dust mites Exposure to tobacco smoke. Predisposed to animals, pollens moulds and dust. Dietary changes – junk food and fast food contain MonoSodium Glutamate

7. Etiology Of Asthma Atopic diseases – eczema and allergic rhinitis. Maternal status – both physical and mental conditions like anaemia and depression in the mother are associated with asthmatic stress for the child. Early antibiotic use – babies who are given antibiotics may be 50% more likely to develop asthma by the age of six

8. Common Triggering Factors Extrinsic (Allergic) Triggers: Dust mites Mould Certain foods Animal dander Pollen Intrinsic (Non-Allergic) Triggers: Exercise Infections (cold and flu) Cold or humid air Intense emotions (ex. Stress) Medications (aspirin) Hormones Air pollution Fragrances and chemicals Occupational irritants

9. Common symptoms of asthma   Coughing, especially at night Wheezing Shortness of breath Chest tightness, pain, or pressure Signs & Symptoms

10. Mild Asthma attack Cough Wheezing Mild difficulty breathing during normal activities Difficulty sleeping Hiccups Peak expiratory flow rate (PEFR) is 70 to 90% of personal best   Symptoms of Asthma attack

11. Moderate asthma attack Severe cough Moderate wheezing Shortness of breath Chest tightness Usually worsens with exercise Inability to sleep Nasal congestion PEFR is 50 to 70% of personal best  Symptoms of Asthma attack

12. Symptoms of Asthma attack Severe asthma attack Severe wheezing Severe difficulty breathing Inability to speak in complete sentences Sentences are interrupted by breathing Inability to lie down Signs of severe difficulty breathing Rib retractions: ribs are visible during each breath  Nasal flaring: nostrils open wide during each breath

13. Symptoms of Asthma attack Use of accessory muscles: neck muscles are prominent during each breath  6. Chest pain Sharp, chest pain when taking a breath, coughing 7. PEFR is <50% of personal best  8. Confusion 9. Rapid pulse 10. Fatigue 11. Rapid breathing rate

14. Symptoms of Asthma attack Severe asthma attack Severe wheezing Severe difficulty breathing Inability to speak in complete sentences Sentences are interrupted by breathing Inability to lie down Signs of severe difficulty breathing Rib retractions: ribs are visible during each breath  Nasal flaring: nostrils open wide during each breath  Use of accessory muscles: neck muscles are prominent during each breath 

15. Symptoms of Asthma attack 6. Chest pain Sharp, chest pain when taking a breath, coughing 7. PEFR is <50% of personal best  8. Confusion 9. Rapid pulse 10. Fatigue 11. Rapid breathing rate

16. Establishing the Diagnosis Not all that wheezes is asthma The Medical history Physical Examination Differential Diagnosis Laboratory Investigations

17. Physical Examination Hyperexpansion of the thorax Sounds of wheezing during normal breathing or a prolonged phase of forced exhalation Increased nasal secretions, mucosal swelling, sinusitis , rhinitis, or nasal polyps Atopic dermatitis/eczema or other signs of allergic skin problem

18. Investigations Peak Expiratory Flow Rate Spirometry Chest Radiograph SkinPrick Testing Measurement of Airway Hyperresponsiveness Sputum Examination

19. Peak Flow Testing Peak Flow Meter PEFR is used to assess the severity of wheezing in those who have asthma. PEFR measures how quickly a person can exhale air from the lungs Peak expiratory flow rate (PEFR)

20. It measures how much air you can exhale. FEV1(force expiratory volume) > 80% = normal Confirms the presence of airway obstruction and measure the degree of lung function impairment. Monitor your response to asthma medications Spirometry (Lung function test)

21. If there are symptoms that may be caused by another condition such as pneumonia, your doctor may want to do a chest X-ray. It also may help to clarify the Problem if there is problem with asthma treatment. Chest X-Ray

22. A drop of liquid containing the allergen in placed on your skin (generally forearms is used). A small lance with a pinpoint is poked through the liquid into the top layer of skin ( prick test). If you are allergic to the allergen, after about 2 minutes the skin begins to form a reaction (red, slightly swollen, and itchy: it makes a hive). The size of the hive is measured and recorded. The larger the hive, the more likely it is that you are allergic to the allergen tested. Allergy-skin Test

23. Allergy-skin test

24. Prevents asthma symptoms from starting Taken daily by people with persistent asthma Brings down inflammation /treats constriction Treatment: Controller Medications Inhaled and oral corticosteroids – not the same as anabolic steroids Leukotriene modifier —alternative to corticosteroids Corticosteroid and long-acting Bronchodilator (LABA)

25. Bronchodilators LABA

26. Reliever vs Controller Medications Reliever Medicines Short acting bronchodilators ( B2 agonists, Ipatropium ) Controller Medicines Inhaled steroids Leukotriene modifiers Long acting beta agonists Theophyllines

27. Step 1 Treatment for Adults and Children >5 : Mild Intermittent Daily Long Term Control Not needed Quick Relief Short-acting inhaled B2-agonist PRN Increasing use, or use more than 2x/week, may indicate need for long term control therapy Intensity of treatment depends on severity of exacerbation

28. Step 2 Treatment for Adults and Children >5 : Mild Persistent Daily Long Term Control Anti-Inflammatory preferred Inhaled corticosteroid (low dose) or Cromolyn or Nedocromil Or Sustained release theophylline (to serum concentration 5-15 mcg/mL) is an alternative but not preferred Leukotriene modifier may be considered

29. Step 2 Treatment for Adults and Children >5: Mild Persistent ( Cont ) Quick Relief Short-acting inhaled B2 agonist PRN Baily or increasing use indicates need for increase long term control therapy Intensity of treatment depends on severity of exacerbation

30. Step 3 Treatment for Adults and Children >5: Moderate Persistent Daily Long-Term Control Inhaled corticosteroid (medium dose) OR Inhaled corticosteroid ( low to medium dose) AND Long acting bronchodilator (long-acting B2-agonist or sustained release theophylline) IF NEEDED, increase to: Inhaled corticosteroid (medium to high dose) and long acting bronchodilator

31. Step 3 Treatment for Adults and Children >5: Moderate Persistent ( Cont ) Quick Relief Short acting inhaled B2 agonist PRN Daily or increasing use indicates increase for long term control therapy Intensity of treatment depends on severity of exacerbation

32. Step 4 Treatment for Adults and Children >5: Severe Persistent Daily long term control Inhaled corticosteroid (high dose) AND Long acting bronchodilator Long –acting inhaled B2 agonists OR Sustained release theophylline OR Long acting B2 agonist tablets AND Oral corticosteroid, long term

33. Step 4 Treatment for Adults and Children >5: Severe Persistent ( Cont ) Quick Relief Short acting inhaled B2 agonist PRN Daily or increasing use indicates need for increase long term control therapy Intensity of treatment depends on severity of exacerbation

34. Treatment of Exacerbation High dose B2 agonist (inhales, sq , IV) Anticholinergics Glucocorticoids- double inhaled cdose or add systemic therapy

35. Bronchial thermoplast y Invasive procedure for severe asthma Is not painful (no nerves inside airways) Risks : mainly lung collapse, bleeding and additional breathing problems, mostly related to the bronchoscope. Precaution: Pt. must be at least 18 y/o to have the procedure. Pt. still need to use their asthma-maintenance medications after the procedure Benefits: Pt. may use rescue inhalers less often and are able to engage strenuous physical activity than before Surgical Treatment