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Asthma

Asthma. Prof. Sevda Özdoğan 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.

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Asthma

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  1. Asthma Prof. Sevda Özdoğan MD, Chest Diseases

  2. 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

  3. Characteristics of the disease: • Chronic inflammation • BHR • Diffuse reversibl airway obstruction

  4. 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

  5. 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

  6. 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

  7. Diagnosis • Measurements of lung function (PFT) • Spirometry (FEV1/FVC<75%) • Peak expiratory flow • Reversibility test (early and late) • PEF diurnal variation monitoring • Nonspecific bronchoprovocation tests (PD20) (measurement of hyperreactivity) • Simple exercise test (6 min)

  8. 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)

  9. 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

  10. Allergens

  11. Acetylsalicylic acid NSAI Beta blockers Contrast agents Cocaine Heroin Dipyridamol Hydrocortisone Beclomethasone inh Pentamidine inh Protamine Vinblastine Mitomycin IL-2 Drugs or agents associated with induction of bronchospasm

  12. 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

  13. 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

  14. 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

  15. Asthma medications • Controllers: • Inhaled corticosteroids (systemic steroids) • Long acting bronchodilators (beta agonist) • Methylxantines (Theophyline) • Leukotriene modifiers • Chromones New drugs: Anti IgE (Omeluzimab)

  16. Relievers: quick relief medicine or resque medicine • Short acting beta2 agonist • Systemic corticosteroids • Theophylline • Anticholinergics

  17. Corticosteroids • The most effective antiinflamatory medications • İmproves lung function • Decreases airway hyperreactivity • Reduces symptoms • Reduces exacerbations • İmproves quality of life

  18. Side effects of systemic (inhaled)steroids • Skin thinning (stria) • Adrenal suppression • Osteoporosis • Arterial hypertension • Diabetes • Cataracts • Glaucoma • Obesity • Muscle weakness • Oropharyngeal candidiasis • Dysphonia • Occasional coughing

  19. Inhaled forms • Drug is delivered directly to the targed • Quick effect • Small doses • Negligable systemic absorbtion • Less side effects

  20. 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

  21. Combined Inh CS+LABA • Improves symptom scores • Improves lung function • Decreases exacerbations and resque medicine use • Side effects: • Cardiovascular stimulation • Skeletal muscle tremor • Hypokalemia

  22. 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)

  23. 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

  24. Chromones • Nedocromil sodium • Sodium chromoglycate • Nonsteroidal anti-inflamatory drugs • Inhibit IgE mediated mediator release • Less effective than corticosteroids

  25. 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

  26. Short acting beta agonists • Salbutamol, terbutaline • Provide rapid relief of symptoms • Duration of action is 4-6 hours

  27. 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

  28. Classification of asthma

  29. Asthma out of control • Check: • Imcompliance to treatment!! • Exposure to precipitating factor? • Respiratory Infection? • GERD? • Psychologic stress?

  30. 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 20-30 100-120 10-25 mmHg %60-80 > 60 mmHg < 45 mmHg %91-95 generalised (Full eksp) Severe Rest (Ortopnea) Word + + Severe > 30 > 120 > 25 mmHg < %60 < 60 mmHg > 45 mmHg < %90 Expiratory and inspiratory

  31. 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

  32. Moderate attack treatment • Nasal O2 1-2 lt/min • İnhaled short acting beta2 agonist+anticholinergic 4-8 puf/20 min/hour then 2-4 puff/hour • Oral or IV prednisolon 0.5-1 mg/kg (divided to 2-4 doses) Continue to treatment 1-3 hours

  33. Severe attack treatment • 4-6 lt/min nasal O2 • 5 mg salbutamol nebulisation/20 min or continious nebulisation 0.15-0.30 mg/kg • (Anticholinergic) 0.5 mg ipratropium bromide nebulisation • IV prednisolon 1-1.5 mg/kg No response after the first 1-2 hours: • Nasal O2 continued • IV prednisolon repeated every 4 hours (Total 120-180 mg/day) • Salbutamol+ anticholinergic nebulisation repeated every 4 hours • IV Aminophyline 6mg/kg in 10-15 min than 0.6-0.9 mg/kg/hr infusion • İv magnesium 2 gr/50 ml SF (30 min infüsion) • sc or ıv adrenaline if necessary

  34. 8-10 hours follow up • Unresponsive to treatment, detoriation; Intensive care • Incomplete remission: Hospitalization (If PEF < %70) • Fine response: Discharge (If PEF > %70)

  35. ventolin bricanyl atrovent combivent Prednol amp Teobag 200mg/100ml

  36. http://kidshealth.org/kid/closet/movies/asthma_movie.html

  37. THANKS

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