ASTHMA

I. OVERVIEW OF THE SYNDROME

II. CATEGORIES OF SEVERITY

III. MANAGEMENT OF ACUTE EXACERBATIONS

DEFINITI0N

•"A chronic inflammatory airway disorder

in which many cell types play a role (mast
cells, eosinophils, and T lymphocytes).
EPIDEMILOGY

• May develop at any age.

• 50- 75% of the cases diagnosed before age 40yrs. New onset asthma
less frequent in the elderly.
• M:F ratio 2:1 in children. Normalization at age 30 yrs.
• Prevalence in Kenya unknown. A paediatric study earlier showed a
prevalence of 10%.US: 4-5% of the population
 PATHOGENESIS
• Airway obstruction due to cellular infiltration and inflammation.
Atopic asthma best described.
• Obstruction occur through out the bronchial tree at onset of attack.
During reversal, larger airways- trachea, bronchi,etc start of ; peripheral
airway dilation may be delayed to several days despite clinical recovery.
This is reflected in Spirometry ie PEFR>PEFR> FEV1 >MMEFR)
PATHOGENESIS

• Susceptible individuals-inflammation causes recurrent episodes of

wheezing, breathlessness, chest tightness, and cough particularly
at night and/or in the early morning. These symptoms are usually
associated with widespread but variable airflow limitation that is at
least partly reversible either spontaneously or with treatment.
• The inflammation also causes an associated increase in airway
responsiveness to a variety of stimuli-hyper responsiveness.
 CLINICAL ASPECTS
• Classic triad: Cough, wheeze + SOB
• These are episodic and may have xtic triggers: exercise, cold weather,
allergens.
• Personal or family H/o atopy.
• P/E often normal.
• Suggestive features: rhonchi- different pitch sounds that vary in duration.
Poor predictor of severity.
• Indicators of severity include:tachycardia,prolonged expiratory phase of
resp. (ie decreased I:E ratio)
• Evaluate for other stigmata for atopy.
 DIAGNOSIS
• Clinical diagnosis usually esp in the acute setting.
• Pulmonary function test indicated in patients whose response to therapy
is not typical of those with severe persistent symptoms.
(i) spirometry- airway obstruction that reverses by >15%
after adm os SABA
(ii)Serial measurement of PEFT- Variability of >20 that
corresponds to symptoms.
(iii)Broncho-provocative testing e.g.
Methacholine or exercise challenge.
 MANAGEMENT PRINCIPLES
• Entails 4 components:

• (i) Routine monitoring of symptoms and lung function

• (ii) Control/ avoidance of trigger factors
• (iii) Pharmacotherapy
• (iv) Patient education
• Goals of Management

(i) Freedom from frequent or severe symptoms including sleep

disturbance.
(ii) Few or no exercabatations requiring medical intervention
(iii) Ability to pursue daily activities
(iv Optimization of lung function
• (v) Minimal or no side effects of medications
(vi) Education of patient and family members about asthma.
 CATEGORIES OF ASTHMA
SEVERITY
• Rationale: Rx recommendations vary according the severity of the dx
• Best validated system: National Asthma Education and Prevention
Program Expert Panel Report ( 1st pub 1997, and updated in 2002)
• One adopted by MOH (Kenya) in the `Consensus Statement on the
Management of Asthma in Kenya’ – a publication of Kenya Association
for the Prevention of Tuberculosis and Lung Diseases.
• Categorization based on 4 criteria:
• Night time awakening due to asthma
• The level of peak expiratory flow (PEF) or forced
expiratory volume in the first second (FEV1),
• The diurnal variability in PEF.
• Daytime symptoms
• 4 categories:
• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe
(I) Mild intermittent

Daytime asthma symptoms occurring two or fewer days per week

 Two or fewer nocturnal awakenings per month

 PEF or FEV1 measurements when asymptomatic that are consistently

within the normal range (ie, 80% of predicted normal)

 Less than 20 percent variability in PEF during the course of a day

(II) Mild Persistent

 Symptoms more than twice weekly and up to several times per week

 More than two nocturnal awakenings per month due to asthma

 PEF or FEV1 measurements when asymptomatic that are consistently

within the normal range (ie, 80% of predicted normal)

 Up to 30 % variability in PEF during the course of a day

(III) Moderate persistent
Daily symptoms of asthma
The development of asthmatic attacks that interfere with activity
 Daily need for bronchodilator medications (either SABA or long-acting)
Nocturnal awakenings more than once per week
PEFR 60 to 80 percent of normal

(iv) Severe
Manifest symptoms with minimal exercise
 Wake more than twice per week at night
Have an FEV1 or PEFR <60 percent of predicted
 Have a widely variable PEFR from day to day
Require multiple asthma medications on a regular basis, including
moderate to high dose ICS
 CLASSIFICATION OF SEVERITY OF ASTHMA

SYMPTOMS NIGHT SX LUNG FUNX

Mild Symptoms 2 times/ week <2 times a FEV1 or PEF

intermittent Asymptomatic and normal PEF between month 80% predicted
exacerbations
PEF variability
Exacerbations brief (from a few hours to a few days); <20 %
intensity may vary
Mild Symptoms >twice/week, but <once/day >X2a FEV1 or PEF 80
persistent month % predicted
Exacerbations may affect activity PEF variability 20-
30%
Moderate. Daily symptoms > 1/ week FEV1 or PEF 60-
persistent Daily use of a short-acting beta 2-agonist 80 % predicted
Exacerbations affect activity5
Exacerbations >2 times/week PEF variability
>30 %
Severe Continual symptoms Frequent FEV1 or PEF 60
persistent Limited physical activity % predicted
Frequent exacerbations PEF variability
>30%
 In categorizing the patient , the clinician should note that:

• The presence of one of the features of severity is sufficient to place a

patient in that category.

• An individual should be assigned to the most severe grade in which any

feature occurs.

• The characteristics noted in this figure are general and may overlap
because asthma is highly variable.

• An individual patient’s classification may change over time

• Patients with any level of severity can have mild, moderate, or severe
exacerbation

• Some patients with intermittent asthma can experience severe and life-
threatening exacerbations separated by long periods of normal lung
function and no symptoms
MANAGEMENT OF ACUTE
ATTACKS
• Attacks should be recognized and appropriately managed early
before they become life threatening
.
• Patients should have been taught (that in case of
attacks) avoidance of offending triggers and self adm. Inhaled
SABA and po corticostreoids.
 Assessment of severity
• Clinical:
• Use of accessory muscles of respiration
• Diaphoresis
• Orthopnea
• Pulsus paradoxicus (fall of sBP of >12mmHg during respiration)
• Spirometry:
• Best tool; value of <200L/minindicates severe attack
• ABGs:
• Normal or >PaCO2 , hypoxaemia
• Pulse oximetry an important alternative in the ED.
Note: CXR not specific (hyper-inflated lung fields) but important in differential diagnosis.
Drug Management

• Goal: Rapid reversal of airway obstruction and correction of

hypercapnia and hypoxaemia.
Patient should receive close monitoring until respiratory
distress is abated.
(I) Inhaled short acting B-agonists (SABA)
Standard of care is Albuterol 2.5mg by continuous flow @
20mins x 3 doses OR continuous by nebulization for
1hr.Salbutamol (Ventolin) is an alternative.Others include
metaproterenol, pirbuterol, levalbuterol and terbutaline.
Intravenous route has no additional benefit and is
associated with more adverse effects.
(II) Inhaled anticholinergics

• Ipratropium in patients with poor initial response to SABA.Dose

500mcg @ 20min for 1- 3hrs of 4 inhalations.
• There is evidence that their addition provides better
bronchodilator activity than SABA alone.
• Some smaller studies argue lack of additional benefit but 2
main meta-analysis showed clear benefit
(III)Systemic steroids
• Enhance recovery due to reduction of inflammation and intra-
luminal mucus plugging.
• Should be administered as soon as insufficient improvement is
noted after initial adm. Of SABA; or <10% improvement in PEF
• Solumedrol 500mg iv bolus or Prednisolone 60- 80mg po stat.
Exact effective dose not clearly established.
(IV)Antibiotics
• Routine use not recommended.
• Clinical judgement can allow their use since studies onto which
this evidence is derived did not consider atypical organisms.
• (V) Others

IV methyl xanthines:
Still in use though recent evidence shows no added benefit
beyond that achieved by above medications

Magnesium sulphate
Act by inhibition of calcium influx into airway smooth muscles. Best left
to specialities.
Adverse Effects of Rx

• B- blockers are associated with the following:

• Tremors
• Tolerance – due to down regulation of B- receptors
• Tachycardia
• Hyperglycaemia
• Hypokalaemia
 Status Asthmaticus
Definition
• Severe attacks of asthma poorly responsive to adrenergic
agents and associated with signs or symptoms of potential
respiratory failure
• Initial management similar to that of acute attacks.

ICU admission/ Mechanical ventilation

• 4% all patients admitted with asthma will need ICU care
• ICU admission associated with 7% mortality.
• Intubation should be cautious because of exaggerated upper
airway hyperesponsiveness.
• Indications for ICU admission

•Slowing of the respiratory rate,

•depressed mental status,
• inability to maintain respiratory effort
• hypoxemia / hypercapnia.

Initial Ventilator settings

•Respiratory rate 10 to 14 breaths/min
•Tidal volume less than 8 mL/kg
•Minute ventilation less than 115 mL/kg
• Inspiratory flow of 80 to 100 L/min
• Extrinsic positive end-expiratory pressure (extrinsic PEEP)
less than 80% of the intrinsic PEEP
• Rarely, airflow obstruction can be so severe that sufficient ventilation
cannot be achieved despite maximal standard therapy.
• In such circumstances, general anesthesia, or extracorporeal life
support may be beneficial.
•Ahsante saaaana