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BRONCHIAL ASTHMA

BRONCHIAL ASTHMA. prof . Mohammad Ali Khan MB, DCH , MRCP(UK) Head of paediatric department SIMS/Services Hospital, Lahore. BRONCHIAL ASTHMA. Definition Reversible Bronchospasm Hyper-reactivity Variability Allergic Disorder Chronic Inflammatory Disorder

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BRONCHIAL ASTHMA

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  1. BRONCHIAL ASTHMA prof. Mohammad Ali Khan MB, DCH, MRCP(UK) Head of paediatric department SIMS/Services Hospital, Lahore.

  2. BRONCHIAL ASTHMA Definition • Reversible Bronchospasm • Hyper-reactivity • Variability • Allergic Disorder • Chronic Inflammatory Disorder Mediated by eosinophils, IgE, mast cells and T-helper lymphocytes. These lymphocytes produce proallergic, proinflammatory cytokines (IL4, IL5, IL13) and chemokines.

  3. PATHOGENESIS Y Antigen Ist exposure II exposure Ig E cAMP GMP Y Ch.mediators Ca++

  4. Theophylline Adrenaline Salbutamol Albuterol Salmetrol Terbutalin adrenergic PD C,AMP MB ATP GMP C h o l i n e r g I c Ipratropium

  5. Precipitating Factors Endogenous ????? Exogenous • Allergens (mostly inhaled) • Food • Infections (mostly viral URTI) • Cold • Exercise • Drugs

  6. Types of Asthma 1. Triggered by Infections 2. Chronic asthma associated with allergy 3. Asthma in obese girls with early puberty 4. Occupational 5. Triad asthma

  7. Clinical presentation • Cough • Dyspnoea • Wheezing • Exercise intolerance • Chest deformity

  8. D/Dasthma commonly wheeze buteverything which wheeze is not asthma • Bronchiolitis • Bronchopneumonia or Bronchitis • BPD • Foreign body • Endobronchial tuberculosis • Enlarged hilar L. nodes compressing upon the main bronchus • Bronchiectasis • Gastroesophegeal reflux

  9. Investigations • CBC, ESR • CXR • S. IgE • Allergy testing • Lung functions • FEV1 : FVC <0.8 • Response to Bronchodilators >12% increase in FEV1 • PEFR • personal Best • Morning-to-evening variation >20% • Exercise challenge • Worsening in FEV1 by >15%

  10. Management • Acute exacerbation • Chronic asthma

  11. Goals Of Management • Maintain normal activity • Normal growth • Prevent sleep disturbance • Prevent chronic asthma symptoms • Keep asthma exacerbations from becoming severe • Maintain normal lung functions • Experience little or no adverse effects oftreatment

  12. Management Of Acute Attack Q. Does Asthma threaten life? A. Commonly not But sometimes YES. (Mortality 0.3 /100,000 population /yr)

  13. Identification Severe Resp Arrest imminent Symptoms Dyspnea At rest Talks in Words Alertness Agitated Drowsy Signs Dyspnea +++ Paradoxical abd- thoracic movements. Wheeze +++ Silent Pulse Tachycardia Bradycardia P. paradoxis >20-40 mm Hg Absent cyanosis ++ +++ Functional Assessment PEFR <50 PaO2 <60 PaCO2 >50 SPO2 <90

  14. Risk Factors • History • Chronic steroid dependent asthma • Prior ICU admission • Prior mechanical ventilation • Recurrent visits to ER during last 48 hrs • Poor compliance with therapy • Resp arrest/ hypoxic seizures or encephalopathy • Cl/Exam • Cyanosis. • Hypotension/ pulsus paradoxis. • Agitation/ drowsiness • Quiet chest • Lab • Hypercarbia, hypoxia, • CXR – Pneumothorax or pneumomediastinum • Therapy • Over-reliance on aerosol therapy • Delayed use of systemic steroids • Sedation • Delayed admission to ICU.

  15. Management: • O2 inhalation • Inhaled Salbutamol/Albuterol Nebulization or MDI • Inhaled Ipratropium • Systemic steroids • Aminophylline infusion • Heliox (70:30 mixture) • Mgso4 infusion (25 mg/kg in 20 min) • Mechanical ventilation.

  16. Management of Chronic AsthmaDrugs Used: • Beta-2 agonists • Non steroidal anti-inflammatory agents • Corticosteroids • Slow release theophylline • Leukotrine modifiers

  17. Beta-2 Agonists • Short Acting • Salbutamol (ventolin) MDI, Neb,Oral,Inj. • Terbutaline (Bricanyl) MDI, Neb,Oral,Inj. • Long Acting • Salmetrol (Serevent) MDI

  18. Non steroidal anti-inflammatory agents • Sodium chromoglycate (Intal) MDI, Spinhaler.

  19. Corticosteroids • Inhaled • Beclomethasone MDI, Neb (Becotide, Becloforte, Clenil A) • Budesonide MDI (Pulmicort) • Fluticasone MDI (Flixotide) • Systemic • Prednisolone

  20. Dosage of inhaled Corticosteroids

  21. Leukotrine Modifiers • Leukotrine Receptor Antagonist • Monteleukast (Singulair) • Zafrileukast (Accolate) • Leukotrine Inhibitors • Zileuton

  22. Slow Release Theophylline • Theodur • Theograd

  23. Step-wise Approach

  24. Rule of ‘3’ 1. Asthma symptoms or >3 times/wk need for bronchodilators 2. Awakes at night because >3 times/mth of asthma 3. Consumption of >3/year bronchodilator inhaler

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