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Attila Somfay. Dept.Pulmonology, University of Szeged, Deszk, Hungary. Asthma. Medical history of D.B. 30-year-old woman, school teacher Complaints for 20 years: periods of S.O.B.,
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Attila Somfay Dept.Pulmonology, University of Szeged, Deszk, Hungary Asthma
Medical history of D.B. • 30-year-old woman, school teacher • Complaints for 20 years: periods of S.O.B., particularly in the August-October period, but also during exercise (tennis), cold air exposure (skie) or under stress (exams). • Severity changes considerably time to time, with frequent attacks of wheezing, between attacks no complaints • Never smoked • Mother also had asthma
Acute admission • Severe attack which responded poorly to BD drugs and inhaled CS. • Exhausted, dehydrated, very anxious • On examination: dyspneic, orthopneic, accessory muscles of respiration were active • Lungs hyperinflated, musical rhonchi in all areas • HR: 110/min with pulsus paradoxus • Sputum scant and viscous
Definition of asthma - inflammatory disorderof the airways, characterized by periodic attacks of wheezing, shortness of breath, chest tightness, and coughing, tipically during the night and early morning. - a condition characterized by recurrent attacks of bronchoconstriction and excessive mucus production, in response to a variety of factors. - the attacks releave spontaneously or by bronchodilators - chronic inflammation results in bronchial hyperreactivity
DEFINITION OF ASTHMA Asthma is a heterogeneousdisease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. NEW! Wenzel, Lancet 2006
Asthma and COPD mortality Mathers, PLos Med 2006
Prevalence of astma (A) and asthmatic symptoms (B) between 1965 and 2005 in children and young adults
Asthma morbidity in Hungary Prevalence Incidence 290 201 15 836 14 629 290 422 OKTPI, 2016
Asthma – variable nature cold weather, exercise allergenes, viruses increases Use os releaver, symptom time Asthma control decreases Exacerbation Exacerbation
Prevalence 3-5% of adults and 7-10% of children. *Half of the people with asthma develop it before age 10 and most develop it before age 30. Asthma symptoms can decrease over time, especially in children. Concomittant diseases Many people with bronchial asthma have an individual and/or family history of allergies such as hay fever (allergic rhinitis) or eczema. Others have no history of allergies or evidence of allergic problems.
Asthma phenotypes Wenzel, Nature Med 2012
Symptom – inflammation relationship Haldar, AJRCCM 2008
Inflammatory cells Mast cell eosinophil Th2 basophil neutrophil platelet Structural cells Epithel Smooth muscle Endothel Fibroblast Nerves Mediators Histamin Leukotrienes Prostanoids PAF Kinins Adenosin Endothelins NO Cytokines Chemokines Growth factors Effects Brochospasm Plasma exsudation Mucus secretion AHR Structural changes
Etiology * In sensitive individuals, asthma symptoms can be triggered by inhaled allergens (allergy triggers) such as pet dander, dust mites, cockroach allergens, pollens. * Asthma symptoms can also be triggered by respiratory infections (virus!), exercise, cold air, tobacco smoke and other pollutants, stress, food or drug allergies. * Aspirin and other non-steroidal anti-inflammatory medications(NSAID) provoke asthma in some patients.
„The September epidemic” (Ontario, Canada, 2001-2004) Johnston & Sears, Thorax 2006
MODERN VIEW OF ASTHMA Allergen Macrophage Mast cell Th2 cell Neutrophil Eosinophil Mucus plug Epithelial shedding Nerve activation Subepithelial fibrosis Plasma leak Oedema Sensory nerve activation Mucus hypersecretion hyperplasia Vasodilatation New vessels Cholinergic reflex Bronchoconstriction Hypertrophy/hyperplasia
Inflammatory and immune cells involved in asthma
Infect theory Th1 – Th2 imbalance
Typical pathologic features: epithel shedding + basement membrane thickening After ICS Before ICS
Effect of inhaled steroid in asthma Laitinen LA, et al. J Allergy Clin Immunol 1992;90(1):32-42
Differences in airway obstruction COPD Asthma
Symptoms 1. *Most people with asthma have periodic wheezing attacks separated by symptom-free periods. *Some asthmatics have chronic shortness of breath withepisodes of increased shortness of breath. *Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted
Symptoms 2. Cough,Wheezing, Dyspnoe -usually begins suddenly - episodic - may be worse at night or in early morning - aggravated by exposure to cold air, by exercise, byreflux - resolves spontaneously or by bronchodilators - cough with or without sputum (dyscrinia) - breathing that requires increased work - intercostal retractions - abnormal breathing pattern: exhalation (breathing out) more than twice as long as inspiration (breathing in)
Dyscrinia (because sputum scant and viscous)
Symptoms 3. Emergency symptoms *extremely difficult breathing *bluish color to the lips and face *severe anxiety *rapid pulse (pulsus paradoxus) *sweating *decreased level of consciousness (severe drowsiness or confusion)during an asthma attack
Signs and tests Listening to the chest (auscultation) during an episode reveals wheezing. Lung sounds are usually normal between episodes. Tests may include: *pulmonary function tests *chest X-ray *allergy testing by skin testing or serum tests (IgE) *arterial blood gas *eosinophil count
Diagnostics -Lung function 1. - Between the attacks: may be normal - During the attacks: obstruction (PEF, FEV1 decreased) - Patients with - normal lung function:provocation test -obstruction:pharmacodynamic test
Lung function 2. Provocation test *Specific provocation-allergen challenge (rarely done, neber in routine,can be dangeorus – anaphylaxis, suffocation) inhalationcauses prompt and sign. bronchoconstriction *rapid decline in FEV1:lasts: 15 min.- 1 hour *=early asthmatic reaction (EAR)=early phase response *After this phase resolves (spontaneously or with -agonist), the FEV1 reaches a level to the pre-chall. baseline. *6-24 hours after exposure to the allergen bronchoconstriction can be developed=late asthmatic response (LAR). The decline in FEV1 may be less severe. *Aspecific provocation (histamin, metacholin): *Exercise test – 6-8 min run, pre/post spirometry Pharmacodynamic test:baseline obstr.lung function, resolved in 15 min due to inh. bronchodilator (salbutamol)
COPD Large airway obstruction Foreign body Tumor VCD Pulmonary embolism Eosinophil pneumonia Chronic cough Bronchitis simplex Sinusitis Tracheitis Dyskinesis CHF Gastroesophageal reflux (GERD) Chronic cough Drug-induced (ACE inhibitor, -blocker) Differencial diagnostics I. Respiratory Non-respiratory
Differencial diagnostics II. • X-ray (chest, sinuses) • Oesophageal pH monitoring • Bronchoscopy, Laryngoscopy • Echocardiography • CT angiography, V/Q scan
Asthma diff. dg.1./A COPD Farmacodynamic test: prae post FVC: 2,00 (47%)- 1,89 (44%) FEV1: 0,93 (28%)- 0,88 (26%) FRC:5,29 (150%)- 5,09 (144%) RV: 4,65 (201%)- 4,57 (198%) Raw: 6,01-6,19 (<2,24) Irreversible obstructive pulmonary disease 61 years old man
Asthma diff. dg.1./B COPD/Emphysema Lung function FVC: 3,05 86% FEV1:1,03 37% VC:3,56 96% FRC:5,93 171% RV: 4,27 173% RV/TLC%: 55% DLCO: 1,6 20% 68 years old man Blood gas analysis pH: 7,42 pO2: 66,6 Hgmm pCO2:37,2 Hgmm Sat: 93%
Treatment 1. Controllers (Anti-inflammatory) - ICS, inhaled corticosteroid: (budenosid, fluticasone, beclomethason, ciclesonide) - leukotriene inhibitors (montelukast, zafirlukast, pranlukast) - LABA(long acting beta-2 agonists) – salmeterol, formoterol – only with ICS - xantin derivates (teophyllin) - Biological therapy:omalizumab (anti IgE) mepolizumab (anti IL-5)
Treatment 2. Releavers (bronchodilators ) - beta-2 agonist: short(fast)-acting (SABA): inhaled (salbutamol, terbutalin, formoterol) - aminophylline or theophylline (I.v) - anticholinergics inhaled (ipratropium)
