Prof. Sevda zdoan MD, Chest Diseases
Asthma Prof. Sevda zdoan MD, Chest Diseases DEFINITION Asthma is a chronic inflammatory disorder of the airways that causes a bronchial hyperreactivity which leads to recurrent episodes of reversible airflow obstruction with wheesing, breathlesssness, chest tightness and coughing Characteristics of the disease:
Chronic inflammation BHR Diffuse reversibl airway obstruction Bronchial hyperreactivity Airway wall remodeling
Genetic predisposition: Multiple genes, Risk in a child is 20-30% if one parent has asthma; 70% if both the parents have asthma + Environmental factors: High allergen exposure (dust mite, cat, dog, fungi etc); Passive smoking; Respiratory infections; air pollution;occupational exposure INFLAMATION Bronchial hyperreactivity Airway wall remodeling Airflow limitation Symptoms Clinical signs and symptoms
Asthma can be diagnosed on the basis of symptoms Episodic breathlessness Wheesing Chest tightness Cough (sometimes thick sputum) Seasonal variability of symptoms Family history of asthma or atopic disease Physical examination Normal (Does not exclude asthma!!)
Wheesing on oscultation (Dyspnea, wheesing, hyperinflation are more likely to be present during symptomatic periods) Wheesing can be absent in severe asthma (silent chest) Cyanosis Drowsiness Difficulty in speaking Tachicardia Hyperinflated chest Accesory muscle activation with intercostal recession Diagnosis Measurements of lung function (PFT)
Spirometry (FEV1/FVC200ml art olmas Ge reversibilite 2-6 haftalk inhale veya sistemik steroid tedavisi sonras tekrarlanan FEV1 ve FVC de %15, PEF de %20 lik art olmas Chest x-ray (important in differential diagnosis)
Sputum or nasal smear eosinophyls Measurement of allergic status Skin testing Specific Ig E in serum (A positive test does not mean allergic asthma so must be confirmed by history of exposure and attack) Factors that precipitate asthma exacerbations (Triggers)
Allergens (indoor and outdoor) Respiratory infections (RSV, Influensa) Exercise and hyperventilation Cold air, weather changes Foods, additives and drugs Irritant gases (air polution, smoking) Extreme emotional expression Occupational agents Gastroesophageal reflux Chronic rhinosinusitis Smoking passive or active Allergens Drugs or agents associated with induction of bronchospasm
Acetylsalicylic acid NSAI Beta blockers Contrast agents Cocaine Heroin Dipyridamol Hydrocortisone Beclomethasone inh Pentamidine inh Protamine Vinblastine Mitomycin IL-2 Different Diagnostic Groups
Asthma in Elderly (differentiation from cardiac asthma, drug effects, changes in the perception of symptoms, difficulty in performing PFT, false positive reversibility) Occupational Asthma Cough variant asthma Exercise induced asthma Samter syndrome Asthma in pregnancy The younger the child, the greater the likelihood that an alternative diagnosis may explain recurrent wheese Samter syndrome, astma, aspirin intolerance and nasal poliposis, sinusitis Treatment Goals in Asthma
Prevent asthma attacks Achieve and maintain control of symptoms Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise (Increase life quality) Avoid adverse effects of medication Prevent development of irreversibl airflow limitation Prevent asthma mortality Treatment program Educate patients to develop a partnership in asthma management Assess and monitor asthma severity Avoid or control asthma triggers Establish individual medication plans Establish plans for managing exacerbations Provide regular follow-up care Asthma medications Controllers:
Inhaled corticosteroids (systemic steroids) Long acting bronchodilators (beta agonist) Methylxantines (Theophyline) Leukotriene modifiers Chromones New drugs: Anti IgE (Omeluzimab) Relievers: quick relief medicine or resque medicine
Short acting beta2 agonist Systemic corticosteroids Theophylline Anticholinergics Corticosteroids The most effective antiinflamatory medications
mproves lung function Decreases airway hyperreactivity Reduces symptoms Reduces exacerbations mproves quality of life Side effects of systemic (inhaled)steroids
Skin thinning (stria) Adrenal suppression Osteoporosis Arterial hypertension Diabetes Cataracts Glaucoma Obesity Muscle weakness Oropharyngeal candidiasis Dysphonia Occasionalcoughing Inhaled forms Drug is delivered directly to the targed Quick effect
Small doses Negligable systemic absorbtion Less side effects LABA Formeterol, Salmeterol Relax airway smooth muscle
Decrease vascular permeability Enhance mucosilier clearance Modulate mediator release from mast cells and basophyls Activity persists for 12 hours Combined Inh CS+LABA Side effects: Improves symptom scores
Improves lung function Decreases exacerbations and resque medicine use Side effects: Cardiovascular stimulation Skeletal muscle tremor Hypokalemia Methylxantines (Theophylline)
Bronchodilator effect (8-12 mg/ml) related to phosphodiesterase inhibition) Antiinflamatory effect (5-10 mg/ml) Used in add-on therapy (Stimulation of respiratory center, diuretic) Side effects: Nausea, vomiting Tachycardia, arrhytmia Seizures, death (>20 mg/ml) Leukotriene modifiers
Montelucast, Zafirlucast, Zileuton Inhibit the effects of cysteinyl leucotriens released from mast cells and eosinophyls Used in add on therapy to reduce the CS dose in moderate and severe asthma Chromones Nedocromil sodium Sodium chromoglycate
Nonsteroidal anti-inflamatory drugs Inhibit IgE mediated mediator release Less effective than corticosteroids Specific Immunotherapy
Subcutaneus or sublingual administration of allergen extracts Very limited indication Greatest benefit in patients with allergic rhinitis that has been unresponsive to conventional pharmacotherapy or specific environmental control Short acting beta agonists
Salbutamol, terbutaline Provide rapid relief of symptoms Duration of action is 4-6 hours Anticholinergics Ipratropium bromide (short acting)
Block the effect of acethylcoline released from cholinergic nerves in the airways Less potent bronchodilators than beta agonists in asthma Side effects: Dryness of mouth, bitter taste Glacoma Uretral spasm Asthma out of control Check: Imcompliance to treatment!!
Exposure to precipitating factor? Respiratory Infection? GERD? Psychologic stress? End ekspiratory wheese Moderate Talking Few words +
Breathlesness Speaking Agitation Accesory muscle activity Wheesing Respir Rate Pulse Pulsus paradoksus PEF PaO2 PaCO2 SaO2 Oscultation Mild attack Walking Sentences - Mild < 20 < 100 < 10 mmHg > %80 Normal < 45 mmHg > %95 End ekspiratory wheese Moderate Talking Few words + Severe 20-30 10-25 mmHg %60-80 > 60 mmHg < 45 mmHg %91-95 generalised (Full eksp) Severe Rest (Ortopnea) Word + > 30 > 120 > 25 mmHg < %60 < 60 mmHg > 45 mmHg < %90 Expiratory and inspiratory Pulsus paradoksus: atakta intraplevral negatif basncn artmasna bal inspiryumda sistolik basncn ekspiryuma gre daha dk olmas Treatment in mild attack
inhaled short acting beta2 agonist 4-8 puff every 20 min for the first hour/ nebulization (2,5 mg) 1-2 times O2 optional If incomplete improvement after the first hour repeat the protocole Partial improvement: moderate attack treatment Moderate attack treatment
Nasal O2 1-2 lt/min nhaled short acting beta2 agonist+anticholinergic 4-8 puf/20 min/hour then 2-4 puff/hour Oral or IV prednisolon mg/kg (divided to 2-4 doses) Continue to treatment 1-3 hours Severe attack treatment
4-6 lt/min nasal O2 5 mg salbutamol nebulisation/20 min or continious nebulisation mg/kg (Anticholinergic) 0.5 mg ipratropium bromide nebulisation IV prednisolon mg/kg No response after the first 1-2 hours: Nasal O2 continued IV prednisolon repeated every 4 hours (Total mg/day) Salbutamol+ anticholinergic nebulisation repeated every 4 hours IV Aminophyline 6mg/kg in min than mg/kg/hr infusion v magnesium 2 gr/50 ml SF (30 min infsion) sc or v adrenaline if necessary 8-10 hours follow up Unresponsive to treatment, detoriation; Intensive care Incomplete remission: Hospitalization (If PEF < %70) Fine response: Discharge (If PEF > %70) ventolin bricanyl atrovent combivent Prednol amp Teobag 200mg/100 ml THANKS