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Bronchial Asthma

Bronchial asthma is a chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. It is caused by a combination of genetic and environmental factors such as allergens, smoking, infections, exercise, and emotions. During an asthma attack, triggers activate mast cells to release inflammatory mediators causing bronchospasm and airway inflammation. Diagnosis involves spirometry, peak flow monitoring, and testing for allergen sensitivity. Treatment consists of reliever medications for acute symptoms and controller medications like inhaled corticosteroids to prevent symptoms. Exacerbations are treated with bronchodilators and systemic corticosteroids.

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31 views

Bronchial Asthma

Bronchial asthma is a chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. It is caused by a combination of genetic and environmental factors such as allergens, smoking, infections, exercise, and emotions. During an asthma attack, triggers activate mast cells to release inflammatory mediators causing bronchospasm and airway inflammation. Diagnosis involves spirometry, peak flow monitoring, and testing for allergen sensitivity. Treatment consists of reliever medications for acute symptoms and controller medications like inhaled corticosteroids to prevent symptoms. Exacerbations are treated with bronchodilators and systemic corticosteroids.

Uploaded by

Aisha
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Bronchial Asthma.

Definition

• Asthma is a heterogeneous disease, usually characterised by chronic reversible airway


resistance due to airway inflammation, bronchospasm and mucus production.
Associated with airway hyperresponsiveness.
• It can be:
◦ reccurent
◦ episodic
◦ variable
Aetiology:

• Combination of genetic and environmental factors.


• Allergens – House dust mites, fungus, animal hair [pets], pollen, fish food, pests
[cockroaches], mould
• Smoking – Tobacco
• Drugs – Aspirin, Histamine, Beta blockers
• Climate – Exposure to cold or dry air, foggy or rain days
• Infections – Rhinitis, Sinusitis→ viruses circulate in winter and autumn
• Exercise – “Exercise induced asthma”→ take salbutamol pre-workout
• Occupation – “Occupational Asthma” eg: Farmers, barbers, bakers
• Emotions – “Psychosomatic Asthma”
• Aerosol Chemicals
Pathophysiology:

1. Trigger activates mast cells


2. Mast cells release spasmonegesn and chemotaxins
3. Spasmonegens (eg histamine, PGs, leukotrines) → bronchspasm (early phase)
4. Chemotaxins (attract neutrophils and monocytes)→ inflammation (late phase)
Clinical Features:

1. Anamnesis –

Symtoms:

Pulmonary

• Recurrent dry cough- with diurnal variation + worse at night


• Recurrent wheeze
• Recurrent difficult breathing (SOB/dyspnoea)
• Recurrent chest tightness
Extra-Pulmonary

• dizziness
• anger
• fear of being alone
• tired
• anxiety and depression
• obesity
• CV and metabolic disease
Past History

• Respiratory diseases in childhood


• Recurrent diseases
• Previous treatment - immunosuppressive drugs, radiotherapy, antibiotics, hormones,
operations, etc.
◦ tx can causes symptoms of respiratory pathology
Comorbidities

Family History

• Allergy/ Atopy
• Contagious diseases (Tuberculosis, COVID 19)
• Genetic diseases, etc.
RFs

• Smoking – packs per day for x years !!!


• Alcoholism→ immuno-compromised so sussceptible to infections
• Drug abuse
Social Status/ living conditions

• Poverty - malnutrition, living in a crowded and poorly ventilated place


• Prison
• Nursing home and other social institutions
• Military boarding house, campus, etc.
Occupation

2. Physical Examination:

• Often normal
• The most frequent finding is wheezing on auscultation, especially on forced expiration
• Severe attack: cannot complete sentences, pulsus paradoxus, hyperinflated chest, RR> 25,
HR > 110, PEF 33-50%
• Life threatening attack: exhaustion, cyanosis, silent chest, O2 sat <92%, low HR, low BP,
PEF <33%, resp acidosis.
Diagnosis:

1. Spirometry with BDT


◦ FEV1/FVC ratio below lower normal test (<0.7)
◦ BDT [Bronchodialator Reversibility Test] - An increase in FEV1 of ≥12% and 200
ml 10–15 minutes after 200–400 mcg salbutamol or equivalent indicates reversible
airflow limitation consistent with asthma
◦ Normal results if asthma is controlled!
2. Peak flow monitoring - PEF monitoring with peak flow meter - variability (diurnal
variation of PEF of > 20% suggests asthma)
3. Fractional Exhaled nitric oxide test - breathing into a mouthpiece attached to a machine
that measures the level of nitric oxide gas in your breath >40ppb.
4. Skin tests for allergy: Skin prick test, Intradermal test, Skin patch test
5. *Sputum Sample ***– Eosinophilia
6. Blood Test – Elevated IgE
7. X-ray – to exclude other disease or comorbidity
◦ No actual findings on X-ray for Asthma
◦ But is used for DDx
GENA guidline

Treatment:

Reliever medications:→ Symptomatic Tx

1. Short-acting inhaling beta - 2 - agonists(SABA) e.g. salbutamol via inhalers or nebulisers


2. Short-acting inhaled anticholinergics a.k.a Short-acting Muscarinic Agonists (SAMA) e.g.
ipratopium bromide
3. Low dose ICS + Formoterol (type of LABA)
◦ Beclomethasone + Formoterol
◦ Budesonide + Formoterol
4. Theophylline
5. Oral SABA
Controller medications:→ Anti-inflammatory Tx

1. Inhaled glucocorticosteroids (ICS)


◦ micrograms
◦ Limited side effects because small dose
◦ Most common SE is Candidosis in mouth
2. Long-acting inhaling beta - 2 - agonists(LABA) always combined with ICS
3. Long-acting inhaled anticholinergics e.g. Tiotropium by soft-mist inhaler→ add on
4. Leukotriene modifiers
5. Slow-release theophylline
6. Systemic glucocorticosteroids→ add on
7. Anti-IgE (omalizumab)→ add on
8. Anti- IL5 (mepolizumab)→ add on
9. Cromones

Non pharmacological interventions: • Avoidance of tobacco smoke exposure • Physical activity •


Avoid medications that may worsen asthma • Remedaition of dampness or old in homes

Reviewing response and adjusting treatment

• How often should asthma be reviewed? 1-3 months after treatment started then every 3-12
months. During pregnancy, every 4-6 weeks. After exacerbation, within 1 week.
• Stepping up asthma treatment:
1. Sustained, for at least 2-3 months if asthma is poorly controlled. First check for
common causes.
2. Short-term, for 1-2 weeks e.g. with viral infection or allergen. May be initiated by
patient with written asthma action plan
3. Day to day adjustment. For patients prescribed low dose ICS
• Stepping down treatment: considered after good control maintained for 3 months.
Asthma Exacerbation (flair-up, attack)

• An abrupt and/or progressive worsening of asthma symptoms with decreased pulmonary


function as a measured by spirometry or peak flow and/or increased use of bronchodilators.
• Exacerbations usually occur in response to exposure to an external agent (e.g. viral upper
respiratory tract infection, pollen or pollution) and/or poor adherence with controller
medication/
Treating exacerbations in primary care

• repetitive administration of short acting inhaled bronchodilators


• early introduction of systemic corticosteroids
• controlled flow oxygen
• For mild to moderate exacerbations, repeated administration of inhaled SABA (up to 4–10
puffs every 20 minutes for the first hour) is usually the most effective and efficient way to
achieve rapid reversal of airflow limitation.
• After the first hour, the dose of SABA required varies from 4–10 puffs every 3–4 hours up
to 6–10 puffs every 1–2 hours, or more often. No additional SABA is needed if there is a
good response to initial treatment (e.g. PEF >60–80% of predicted or personal best for 3–4
hours)
◦ Improving – Continue treatment with SABA as needed, Assess response at 1 hour
(or earlier)
◦ Worsening – Transfer to acute care facility, While waiting give inhaled SABA and
ipratropium bromide, O2, systemic corticosteroid, MgSO4 iv
Not recommended during asthma attack!

• Sedatives
• Mucolytics
• Physiotherapy
• Hydration with large volumes of fluid
• Antibiotics (only if there is indication for bacterial infection)
• Epinephrine/adrenaline (may be indicated for acute treatment of anaphylaxis and
angioedema

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