MANAGEMENT OF CHRONIC BRONCHIAL ASTHMA.pptx

this is about bronchial asthma and its symptomatic treatment
its a a hypersensitivity chrnoic obstruction of airways

1. Bronchial asthma By M.N.S.Anusha Roll no-79

2. Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation and variable expiratory airflow obstruction that produces symptoms such as wheezing, shortness of breath, chest tightness and cough which vary over time and in intensity .

3. Symptomatic episodes are most likely to occur at night or in early morning and are produced by bronchoconstriction that is at let partly reversible, either spontaneously or with treatment Rarely an unremitting attack called acute severe asthma may prove fatal; usually such patients have a long history of asthma. Between the attacks they are virtually asymptomatic . Asthma has several distinct clinical phenotypes, each with different underlying pathogenic mechanisms. In all types, episodes of bronchospasm may have diverse triggers .

4. Triggers of asthma Infections : viral infections in young children are important triggers of airway narrowing. Viral infections might effect the integrity of the mucosal surface resulting in the mucosal edema and mucous secretions Exercise : it occurs in genetically susceptible individuals with hyperactive airways, evaporative water loss is seen from the respiratory tract which induces mucosal hyperosmolarity which stimulates mediator release from mast cells. Weather : sudden change of weather may result in- (i)evaporative water loss from lower airways; and (ii)release of airborne allergens in atmosphere that exacerbate asthma.

5. Emotions : stress, through the vagus nerve may initiate bronchial smooth muscle contraction. Food : allergy to food proteins or additives has an insignificant role in pathogenesis of asthma Endocrine : children may get increase in symptoms during puberty

6. ATOPIC NON ATOPIC ~ IgE mediated ~It is triggered by allergens It is non IgE mediated It has several subtypes like - drug induced -mixed -exercise induced

7. Pathophysiology Diffuse airway obstruction in asthma caused by - (i)edema and inflammation of mucous membrane lining the airways (ii)excessive secretion of mucus, inflammatory cells and cellular debris, and (iii)spasm of smooth muscle of bronchi

8. Clinical features The clinical features of asthma vary from recurrent cough to severe wheezing symptoms occur with season change Acute asthma it begins with bouts of spasmodic coughing, the patient is dyspneic In severe episodes the child shows air hunger and fatigue. The presence of cyanosis cardiac arrythmias indicates severe illness

9. Diagnosis Diagnosis is clinical in most cases pulmonary function tests(PEFR,FEV1,FVC,FEV25-27) Absolute eosinophil counts Chest x-ray film Allergy tests

10. Differential diagnosis Bronchiolitis Congenital malformations Aspiration of foreign body Hypersensitivity pneumonitis Cystic fibrosis

11. THANK YOU

12. Management of Asthma PRIYA KONI ROLL NO 61

13. Goals of therapy Identification and elimination of exacerbating factors Pharmacological therapy Education of patient and parents of the disease and steps to avoid acute exacerbation

14. Identify and eliminate exacerbating factors The bedroom should be clean and dust free. Wet mopping on floor is advised Instead of heavy tapestry, light plain cloth sheets to be used as curtains in childs bedroom Regular and overall dusting of household items like furniture and carpets Child if allergic to pet fur, pets to be kept away from them Allergic teenagers should refrain from smoking Strong odors such as wet paint, disinfectants and smoke to be minimised Child should avoid attics and basementsif unoccupied and closed

15. Bronchodilators: Adrenaline given subcutaneously Inhalation route preferred because rapid onset of action and few side effects Long acting have delayed onset of action of about an hour but last for 12 to 24 hours

16. Corticosteroids Used in long term treatment of asthma Systemic steroids used in early therapy reduces emergency hospital admission Commonly used are beclomethasone, budesonide and fluticasone Side effect of long term steroid treatment is slowed growth velocity in 1 st year by 20% which is recovered in later years

17. Mast cell stabilizers Cromolyn sodium used in mild to moderate persistent asthma and exercise induced asthma Given for 6-8 weeks before declaring it ineffective Others are nedocromil and ketotifen

18. Leukotriene modifiers Used in mild to moderate asthma They act either by decreasing synthesis of leukotrienes (zileuton) Or by antagonizing the receptors (montelukast and zafirlukast) Montelukast and zafirlukast approved for use in children >1 year of age and >12 years respectively

19. Theophylline It has concentration dependent effects It dilates bronchi by inhibition of phosphodiesterase Anti inflammatory and immunomodulatory effects at therapeutic serum concentration Recently recommended for alternative second-line therapy in moderate persistent asthma in children >5 years As 2 nd line therapy in mild persistent asthma in older children and adults And as adjunctive therapy in moderate and severe asthma

20. Immunotherapy Repeated intervals of Exposure of allergen to sensitive patient so as to acclimatize them towards the allergen This is done in highly selected children who are sensitive to specific allergens eg. Grass, pollen, mites Immunotherapy carried out only under specialist supervision

21. MANAGEMENT OF ASTHMA Roll no 62

22. PHARMACOLOGICAL MANAGEMENT Assessment of symptom control Assessment of risk of exacerbation Selection of medication Selection of appropriate inhalation device Monitoring and modification of treatment

23. ASSESSMENT OF SYMPTOM CONTROL

24. ASSESSMENT OF RISK OF EXACERABATION

25. SELECTION OF MEDICATION

26. SELECTION OF APPROPRIATE INHALATION DEVICE Drugs used by the inhalation route are more effective Rapid onset of action Fewer side effects METERED DOSE INHALER It delivers fixed amount of medication in aerosol form each time it is activated. It requires press-breath coordination(may not possible in children). Used in exacerbation and maintenance therapy. Significant amount of drug deposits in oropharynx.

27. METERED DOSE INHALER WITH SPACER Less impaction in oropharynx , larger proportion of medication being deposited in the lung. They also overcome the problems of poor technique and coordination of actuation and inspiration, which occur with MDI alone. METERED DOSE INHALER WITH SPACER WITH FACEMASK Attaching a face mask to the spacer facilitates their use in young infants.

28. DRY POWDER INHALER(DPI) These are breath-activated devices ( Rotahaler ; Diskhaler , Spinhaler , Turbohaler , Acuhaler ) that can be used in children above 4-5 years old. They are portable and do not require coordination of actuation with breathing. the effect of these inhalers depends on a certain inspiratory flow rate, with risk of reduced effect during acute exacerbations or in children with low pulmonary function. NEBULIZERS Use of nebulized beta-agonist in acute severe asthma, especially in young irritable and hypoxic children who do not tolerate MDI with spacer and face mask. At a flow rate of 6-12 L/min, 30-50% of aerosol is in the respirable range of 1-5 mm. Slow, deep inhalations and breath holding improves delivery.

29. It is necessary to select an appropriate device by which the maintenance medication is administered Children below 4 years of age: MDI with spacer with facemask can be used . For children above 4 years of age: MDI with spacer is preferred. For children above 12 years of age: MDI may be used directly.

30. MONITORING AND MODIFICATION OF TREATMENT After initiating treatment, patients should be seen every 4- 12 weeks. At each visit, history regarding frequency of symptoms, sleep disturbance, physical activity, school absenteeism, visit to a doctor and need for bronchodilators, and PEFR is recorded. The inhalation technique and compliance is checked. Patient is assessed as controlled, partially controlled or uncontrolled If no cause is found, step up, i.e. increase in dose and frequency of medication is required. Step down, if control is sustained for 3-6 months and follow a stepwise reduction in treatment

31. EDUCATION OF PARENTS Education of patients and their parents is an important aspect of management Parents should be asked to maintain a record of daily symptoms such as cough, coryza, wheeze and breathlessness. A record of sleep disturbances, absence from school due to illness and medication required to keep the child symptom-free is advised. These records help in stepping up or down the pharmacotherapy. The parents, and where possible the patient, should understand how the medications work, proper administration, use of spacer and potential harmful effects of drugs. The parent/patient is instructed regarding recognition and management of acute exacerbation of asthma at home.

32. ACUTE EXACERABATION OF ASTHMA An increase in symptoms (cough, wheeze, and/or breathlessness) is termed as exacerbation of asthma. The severity of exacerbation is variable and can be classified as mild, moderate, severe based on physical examination measurement of PEFR/ FEVl and oxygen saturation.

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