BRONCHIAL ASTHMA
Definition
Asthma is a chronic inflammatory disease of the airways
which develops under the allergens influence, associates
with bronchial hyperresponsiveness and reversible
obstruction and manifests with attacks of dyspnea,
breathlessness, cough, wheezing, chest tightness and
sibilant rales more expressed at breathing-out.
causes
Allergic reactions to plants, foreign
bodies in the air way.
Etiology
The allergens are
divided into:
•Communal,
•Industrial,
•Occupational,
•Natural
•Pharmacological
Сommunal allergens are contained in the air of
apartment houses. They are:
House-dust mites
Vital products of domestic insects
Tobacco smoke during active or passive smoking;
Various communal aerosols and synthetic detergents.
Water vapour
Hair and fur of pets
Among the industrial allergens nitric, carbonic,
sulfuric oxides, formaldehyde, ozone and emissions of
biotechnological industry - main components of industrial and
photochemical.
The most important occupational allergens are dust
of stock buildings, weaving-mills, book depositories
Natural allergens are represented by plant pollen and
different respiratory, particularly viral infections
Some allergens which may cause asthma
Spittle, excrements,
House-dust mites which live in
carpets, mattresses and hair and fur
upholstered furniture of domestic
animals
Plant pollen
Dust of Pharmacological Food
book agents (enzymes, components
depo- antibiotics, (stabilizers,
sitories vaccines, serums) genetically modified
products)
Asthma Triggers
©2010
Trigger-factors, which provoke bronchospasm,
are: a simultaneous penetration of a large quantity of
allergen, viral respiratory infection, hyperventilation,
physical exertion, emotional stress, becoming too cold,
adverse weather conditions, administration of some
medicines (aspirin, -blockers).
Pathophysiology
Asthma pathophysiology is quite difficult and insufficiently
studied. Undoubtedly, in most cases the disease is based
on 1 type hypersensitivity reaction in which increasing
level of IgE secondary degadation of mast cells release of
mediatos like cytokines and prostaglandins and histamine
lead to bronchoconstriction .
Classifications of Asthma
1. Spasmodic: sporadic in nature with varying
intervals of free and difficulty due to precipitating
factors often readily defined.
2. Continuous: some shortness of breath on
occasion, transit wheezing on strenuous exercise and
wheezy rales hard deep inspiration.
Classifications of Asthma cont…
3. Intractable: persistent wheezing requiring
regular daily medication for either control of
symptoms or ability to function.
4. Status Asthmaticus: sever attach in which
patient deteriorates in spite of adequate
treatment.
Clinical manifestations
Classic signs and symptoms of asthma are:
Attacks of expiratory dyspnea
Shortness of breath
Cough.
Chest tightness
Wheezing (high-pitched whistling sounds when
breathing out)
Sibilant rales
In typical cases in development of asthma
exacerbation there are 3 periods – prodromal period, the
height period and the period of reverse changes.
At the prodromal period:
vasomotoric nasal reaction with profuse watery
discharge,
sneezing, dryness in nasopharynx,
paroxysmal cough with viscous sputum,
emotional lability,
excessive sweating,
skin itch and other symptoms may occur.
At the peack of exacerbation there are:
expiratory dyspnea
forced position with supporting on arms
poorly productive cough
cyanotic skin and mucous tunics
hyperexpansion of thorax with use of all accessory muscles during
breathing
at lung percussion: tympanitis, shifted downward lung borders
at auscultation: diminished breath sounds, sibilant rales, prolonged
breathing-out, tachycardia.
in severe exacerbations: the signs of right-sided heart failure
(swollen neck veins, hepatomegalia), overload of right heart
chambers on ECG.
At the period of the reverse changes,
Which comes spontaneously or under
pharmacologic therapy.
Dyspnea and breathlessness relieve or disappear.
Sputum becomes not so viscous.
Cough turns to be productive.
Patient breathes easier.
Asthmatic status
The severe and prolonged asthma exacerbation with intensive
progressive respiratory failure, hypoxemia, hypercapnia,
respiratory acidosis, increased blood viscosity and the most
important sign is blockade of bronchial 2-receptors.
Stages:
1st - refractory response to 2-agonists (relaxation of the smooth muscles)
2nd - “silent” lung because of severe bronchial obstruction and
collapse of small and intermediate bronchi;
3rd stage – the hypercapnic coma.
In many cases asthma, particularly intermittent, manifests
with few and atypical signs:
episodic appearance of wheezing;
cough, heavy breathing occurring at night;
cough, hoarseness after physical activity;
“seasonal” cough, wheezing, chest tightness
the same symptoms occurring during contact with
allergens, irritants;
lingering course of acute respiratory infections.
Acute severe asthma
PEFR 33-50% predicted
Respiratory rate >25 breath/min
Heart rate >110
Inability to complete sentences in 1
breath
Wheezy chest
Life threatening asthma
imbending for ICU admission
Laboratory parameters Clinical features
PEFR<33% Silent chest
Cyanosis
SPO2<92% Bradycardia
Pao2<8kpa Hypotension
paCo2<6kpa Confusion
Leucocytosis >16000/ccm DCL
CRP>45 Coma
Elevated procalcitonin
Diagnosis
Typical clinical
manifestations
and lung function
assessment are
sufficient for
diagnosis of
asthma.
Clinical diagnosis of Asthma
Positive reversibility test: which means
improving FEV in 1st second and 20
minutes of taking bronchodilators
according to this diagram
Positive reversibility test
Laboratory diagnosis
Elevated level of IgE
Elevated eosinophils
Elevated histamine
Performing HRCT chest is mandatory
Management
1. Avoiding the contact with allergen. If it is impossible, the
specific hyposensitization with standard allergens should be
performed. It is rather effective in case of monoallergy, in
intermittent and mild persistent asthma, in remission phase.
2. Elimination of trigger factors (rational job placement,
changing the residence, psychological and physical adaptation,
careful drug using) is the second condition for successful asthma
treatment.
3. Optimally selected medical care is the base of asthma
management.
Stepwise approach in management of bronchial
asthma
Stepwise approach
Step 1: short actingβ2 agonist
(salbutamol inhaler )
STEP 2
Low dose of Inhaled corticosteroids
EX: Beclomethasone, Budsonide,
fluticasone
Dose :200μgm
Leukotriens receptor antagonists
EX: Montelukast,Zafirlukast
Dose:10mg
STEP 2
STEP 3
Long acting β2 agonists : Salmetrol and
formetrol
Moderate dose of ICS
DOSE:200-800µgm
Combinations : ICS+LABA
Symbicort:budesonide+formetrol
Sertide discus: fluticasone+salmetrol
STEP 4
High dose of ICS
Leukotriens Receptors antagonists
Dose:800-2000µgm
STEP 5
Oral corticosteroids : prednisolone
Dose: 5-20 mg
Monoclonal antibodies anti- IgE
EX:Omalizumab/ monthly
Side effects of steroids
Cataract
Stress ulcer
Hyperglcaemia
Osteoprosis
Myopathy
Hypertension
Weight gain
Cushing syndrome
Oral candidiasis
Management of
asthmatic status
Oxygen
Systemic corticosteroids (Hydrocortisone 200mg or Prednisolone 50
mg/day per)
Inhalations of short-acting 2-agonists - Salbutamol 5mg or Fenoterol
2mg through nebulaser – 3 times at 1st hour, then once an hour till
distinct improvement of patient’s condition is achieved; then 3-4 times
a day.
Inhaled anticholinergic drugs or Aminophylline IV.
If ineffective - artificial lung ventilation.
Prognosis
In case of early detection and adequate
treatment the prognosis for the disease is
favourable.
It becomes serious in severe persistent and
poorly controlled (insensitive for corticosteroids)
asthma.
Prophylaxis
Preservation of the environment, healthy
life-style (smoking cessation, physical training)
– are the basis of primary asthma prophylaxis.
These measures in combination with adequate
drug therapy are effective for secondary
prophylaxis.
Thank you
