11. BRONCHIAL ASTHMA
Hyperresponsiveness of tracheo-bronchial
smooth muscle
resulting in narrowing of bronchial tree
Wheezing attacks
polygenic
Primarily inflammatory condition
12.
13.
14.
15.
16. Mediators in Asthma
Mediators released are > 100 in number
histamine, TNFa - immediate
Prostaglandins, leukotrienes, PAF –
within min
Interleukins, TNFa – /over hrs
17.
18.
19.
20. Symptoms of Asthma
• Wheezing
• Cough, especially at night
• Chest tightness
• Shortness of breath
• Characteristically occur or worsen at night,
with exercise, with viral infections, or with
exposure to dust, animals, or smoke
35. JOKE WITH ASTHMA
Matthew sets up Andrew to go on a blind date
with a friend of his.
But Andrew is a little worried about going out with
someone he has never seen before.
“What do I do if she’s ugly?” says Andrew, “I’ll
be stuck with her all night.”
“Don’t worry.” Matthew says. “Just go up to her
door and meet her first. If you like what you see,
then everything goes as planned. If you don’t,
just shout Aaauuuggghhh! and fake an
36. JOKE WITH ASTHMA
So that night, Andrew knocks at the girl’s door,
and when she comes out he is awe-struck at
how beautiful and sexy she is.
Andrew’s about to speak when the girl
suddenly shouts, “Aaauuuggghhh!”
38. SALBUTAMOL
Beta2 stimulation inc.cyclic AMP
relaxation, decreases mediator release
Fastest acting , within 5 min, lasts for 2-4 hrs
Relieves symptoms
Used to abort acute attacks of asthma
ADR – tremors, palpitation, restlessness,
ankle edema, hypokalemia
Orally in severe asthma
Regular use – downregulation of receptors
39.
40.
41.
42.
43.
44.
45. TERBUTALINE
Similar to salbutamol
Used only for symptomatic relief
46. BAMBUTEROL
Prodrug
Hydrolysed by pseudocholinesterase into
active drug
Release over 24 hrs
Indicated in chronic bronchial asthma
Single evening dose 10 -20 mg
47.
48. SALMETEROL
Long acting beta2 agonist
Slow onset of action
Used by inhalation
Twice a day schedule
For maintenance therapy and nocturnal
asthma
49. FORMOTEROL
Long acting beta2 agonist
Acts for 12 hrs when inhaled
Fast acting as well
Used as a Regular twice a day schedule for
round the clock bronchodilatation.
50.
51. OTHER BETA AGONISTS
Adrenaline, ephedrine, isoprenaline
Less safe – cause cardiac arrhythmias
52.
53. Worried Patient
Patient: Doctor, when I press my leg it
hurts. Then when I press my chest it hurts,
when I press my head it hurts, and when I
press my stomach it hurts. I'm worried doc,
what's wrong with me?
Doctor:
Easy straightforward, you have a sore
finger!
54. THEOPHYLLINE
Xanthine alkaloid
Good bronchodilator
Inhibit phosphodiesterase 5, release Ca, block
adenosine receptors
CNS stimulant,
increases HR, Diuretic, increases acid
secretion,
dilate bronchi
Also used in COPD
Has low therapeutic index
Use has declined because of safety
55.
56.
57.
58.
59.
60. THEOPHYLLINE - ADR
Insomnia, nervousness, flushing
Tremors
Vomiting
Palpitation
Arrhythmias, seizures in high doses
61.
62.
63.
64.
65.
66.
67.
68. THEOPHYLLINE – DRUG
INTERACTIONS
Microsomal enzyme inhibitors increases
toxicity
Enzyme inducers decrease levels
Theophylline enhances the effects of
furosemide, sympathomimetics,
hypoglycemics
PK – elimination changes 1st order to 0 order
Has low therapeutic index – need monitoring
72. ANTIMUSCARINIC
BRONCHODILATORS
Ipratropium bromide, oxitropium, tiotropium
Block M3 receptors
Inhaled less systemic effects
Slower response
Better suited for regular prophylactic use
Less effective than salbutamol
Useful in COPD, refractory asthma
73.
74.
75.
76. The Specialist
'What kind of work do you do?' a woman
passenger enquired of the man travelling in
her train compartment.
'I'm a Naval surgeon,' he replies.
'My word!' spluttered the woman, 'How you
doctors specialise these days.'
77. CORTICOSTEROIDS
Suppress inflammatory response
Do not dilate bronchi
Afford complete & sustained relief
Decrease disease progression
Inhaled steroids – only few ADR
Long term systemic therapy – more ADR
78. CORTICOSTEROIDS
Prednisolone – given orally
Beclomethasone
Fluticasone
Budesonide all given by inhalation
to minimise systemic side effects
79.
80. Effects of Inhaled Corticosteroids on
Inflammation
Compromis
Compromis
ed
ed
Epithelium
Epithelium Intact
Intact
Thickened BM Epithelium
Epithelium
Thickened BM
Inflammatory Cells
Inflammatory Cells ↓
↓
Inflammatory
Inflammatory
Cells
Cells
Laitinen et al. J Allergy Clin Immunol 1992;90:32-
81. INHALED STEROIDS
High topical activity
‘ Step 1’ for all patients
Indicated if beta2 agonist required daily
ADR – hoarseness of voice, dysphonia,
oropharyngeal candidiasis, sore throat
Safe during pregnancy
> 600 micrograms/day systemic effects
C/I - Infection
82.
83.
84.
85.
86.
87.
88. MAST CELL STABILIZERS
Sodium cromoglycate, nedocromil
Alternative to inhaled steroids
Inhibit degranulation of mast cells – prevent
release of mediators
Given by inhalation
Prevent bronchospasm induced by allergens,
irritants, cold air, exercise
Other Uses – allergic rhinitis, conjunctivitis
ADR- mild, like cough, throat irritation
89.
90.
91.
92.
93.
94.
95.
96. KETOTIFEN
H1Antihistamine
Like cromoglycate
Orally given
ADR – Sedation, dry mouth, weight gain
1-2 mg BD
Also used in other allergic disorders
97.
98.
99.
100.
101. LEUKOTRIENE RECEPTOR
ANTAGONISTS
Montelucast, zafirlucast
Similar efficacy like low dose steroids
Used in prophylaxis alternate to steroids
More acceptable in children
Effective in aspirin induced asthma
Very safe, few side effects- headache, rash
rarely cause churg- strauss syndrome
2nd – 3rd line role
107. ZILUTON
5 Lipoxygenase inhibitor
Prevent all LT induced responses
Efficacy similar to LT antagonists
Limitations – short duration, hepatotoxicity
108.
109.
110. OMALIZUMAB
A monoclonal antbody against IgE
Binds to IgE form a complex make IgE
not bind to IgE receptors on mast cells and
basophils inhibition of allergic response
Given S.C once in 2-4 weeks
ADR – Well tolerated, pain at the site of inj.,
allergy
Caution – a very small% developed cancers
Uses – prophylaxis in patients with moderate to
severe asthma >12 years
111.
112. STATUS ASTHMATICUS
Also known as refractory asthma , acute
severe asthma
May be life threatening
A medical emergency
URI is mostly the precipitant
Other triggers – drugs, stress, allergens,
abrupt withdrawal of steroids after prolonged
use
113. A JOKE ON SAVING LIFE
In a school in Poland the teacher asks, "Has
any of you ever saved somebody's life?“
A little boy raises his arm, "Yes, my little
nephew's.“
"How did it happen? Tell us!" asks the teacher.
The little Polack says, "I hid my sister's birth
control pills!"
114.
115. STATUS ASTHMATICUS
Nebulized salbutamol (2.5-5 mg )+ ipratropium
(0.5 mg ) intermittent inhalation
Intermittent high flow humidified Oxygen
inhalation
Hydrocortisone hemisuccinate 100 mg i.v stat
followed by 100 – 200 mg 4-8 hourly infusion
Salbutamol/Terbutaline 0.4 mg i.m/s.c may be
added
Antibiotics
i.v fluids + sodium bicarbonate infusion
Intubation and mechanical ventilation, if needed
NO SEDATION
116.
117.
118.
119. Can I call you Little Asthma?
'Cause you take my breath
away……
Tweet Share
120. CHOICE OF TREATMENT – MILD
EPISODIC ASTHMA
Symptoms < once daily, normal between
attacks
Inhaled beta2 agonist at onset of episode –
step1
Regular Prophylaxis not required
121.
122. SEASONAL ASTHMA
inhaled cromoglycate or low dose
inhal.steroids
Regularly 3-4 weeks before and after season
Individual episodes – short acting inhal. Beta2
agonist
123.
124. MILD CHRONIC ASTHMA
WITH OCCASIONAL
EXACERBATIONS
Symptoms once daily
Regular Low dose inhal. Steroids or
cromoglicate – step2
Episode treatment with short acting inhal.
Beta2 agonist
125.
126. MODERATE ASTHMA with
frequent exacerbations
Attacks affect activity
Occur > 1/day
Increasing doses of Inhal. Steroids upto 800
micrograms/day + inhal. Long acting beta2
agonist – step3
Or LT antagonist for steroids
Theophylline may be used
129. WARNINGS
BETA BLOCKERS even topical or selective
may precipitate asthma
Can be fatal so contraindicated
Overuse of beta2 agonists can cause
asthma related deaths
130.
131.
132. NAEPP Guidelines
Classification of Asthma Severity
4 Severe Persistent
3 Moderate Persistent
2 Mild Persistent
1 Mild Intermittent
133. Asthma Treatment
Summary
Mild Intermittent
Use: salbutamol, Asthma Action Plan
Mild Persistent
Use: salbutamol and Controller medications (low dose
steroids, nedocromil, cromolyn, montelukast)
Moderate Persistent
Use: Combination of medications (low to medium dose
steroid plus long acting beta agonist, and/or Leukotriene
modifiers)
Severe Persistent
Use: High dose inhaled steroids, long acting beta
agonist, and leukotriene modifier. May need oral
steroids
134.
135. PADDY IN THE CONFESSION
BOX
Paddy NcNaughty went to confession : "Bless
me, Father, for I have sinned.“
Priest asked "And what is it that you have done,
my son?"
"I made love to one of the girls in the village.“
"My God!" said the priest, "and which of the
village girls did you commit sin with?"
"Ah, Father, that I cannot tell."
136.
137. PADDY IN THE CONFESSION
BOX
"And if you will not tell me, then I shall not
forgive your sins "
"Ah dear!" said Paddy.
"Was it Molly O'Flaherty?" asked the priest.
"No, it was not Molly O'Flaherty."
"Then was it Flora Fitzgibbons?"
"Ah no," said Paddy, "it was not Flora
Fitzgibbons."
138. PADDY IN THE CONFESSION
BOX
Was it Maggie Muldoon, then?" persisted
the priest.
"Ah, sure no, it was not Maggie Muldoon."
"Then who in heaven's name was it?"
"Ah, sure, Father -- that I cannot tell.“
"And if you don't tell me I shall not give
you absolution."
139. PADDY IN THE CONFESSION
BOX
"Ah, Father, that's too bad!" said Paddy
and walked out of the confessional.
His friend, Michael, was waiting outside.
He asked "Well, Paddy, did you get your
sins forgiven?"
"No," said Paddy, "but I got the names
of few great girls to fun with "
140.
141.
142.
143. LAUGHTER BOOSTS IMMUNE
SYSTEM
Young children laugh an average of 300 times a
day, while adults average somewhere between
15 to 100 times.
The saying that ‘Laughter is the best medicine’
may have some truth to it. Laughing helps to
boost the immune system.