Complete therapeutics on asthma condition

1. Asthma
(Therapeutics)
KRVS Chaitanya

2. Introduction
• Asthma is a relatively common condition that is
characterised by at least partially reversible inflammation of
the airways and reversible airway obstruction due to airway
hyperreactivity.
• It can be:
– Acute,
– Subacute or chronic
– Exercise induced

3. Asthma
• Is a major noncommunicable disease (NCD), affecting both children and
adults.
• Is the most common chronic disease among children.
• Inhaled medication can control asthma symptoms and allow people with
asthma to lead a normal, active life.
• Avoiding asthma triggers can also help to reduce asthma symptoms.
• Most asthma-related deaths occur in low- and lower-middle income
countries, where under-diagnosis and under-treatment is a challenge.

4. Epidemiology
• Asthma is one of the most common chronic diseases in the
world. It is a common pathology, affecting around 15% to 20%
of people in developed countries and around 2% to 4% in less
developed countries.
• It is significantly more common in children.

5. Asthma:
• Affected an estimated 262 million people in 2019 and caused
461000 deaths.
• May occur at any age (significantly more common in
children), most patients with asthma experience their first
symptoms before the age of 5 years old and about 66% are
diagnosed before the age of 18 years.
• Almost 50% of children with asthma have a decrease in
severity or disappearance of symptoms during early adulthood.

6. • Prevalence is greater in extreme of ages due to airway
responsiveness and lower levels of lung function.
• In many countries, including the US, asthma kills one out of
every 100,000 persons.
• Results in millions of school and workdays lost. In the US
alone, close to 2 million asthmatics seek regular care in the
emergency department, which also increases the costs of
healthcare.

7. Aetiology
• Inflammation plays a major role in asthma and involves
multiple cell types and mediators.
• The factors that initiate the inflammatory process are
complex and still under investigation.
1. Genetic factors (eg cytokine response profiles).
2. Environmental exposures (such as allergens,
pollution, infections, microbes, stress) at a crucial time in the
development of the immune system are known to be involved.

9. Risk Factors
• Asthma is more likely if other family members also have asthma –
particularly a close relative, such as a parent or sibling.
• Asthma is more likely in people who have other allergic conditions,
egeczema and rhinitis (hay fever).
• Urbanisation is associated with increased asthma prevalence, probably due
to multiple lifestyle factors.
• Events in early life affect the developing lungs and can increase the risk of
asthma. Eg low-birth weight, prematurity, exposure to tobacco smoke and
other sources of air pollution, viral respiratory infections.

10. • Exposure to a range of environmental allergens and irritants
are also thought to increase the risk of asthma, eg indoor and
outdoor air pollution, house dust mites, moulds, and
occupational exposure to chemicals, fumes, or dust.
• Children and adults who are overweight or obese are at a
greater risk of asthma.

11. Pathophysiology
• Asthma is a condition of acute, fully reversible airway
inflammation, often following exposure to an environmental trigger.
• The pathological process begins with the inhalation of an irritant
(e.g., cold air) or an allergen (e.g., pollen), which then, due to
bronchial hypersensitivity, leads to airway inflammation and an
increase in mucus production.
• This leads to a significant increase in airway resistance, which is
most pronounced on expiration.

12. Comparison b/n COPD vs. Asthma

14. • Airway obstruction occurs due to the
combination of:
– Inflammatory cell infiltration.
– Mucus hyper secretion with mucus plug formation.
– Smooth muscle contraction.
• These irreversible changes may become
irreversible over time due to
– Basement membrane thickening
– Collagen deposition
– Epithelial desquamation.
– Airway remodelling occurs in chronic disease with smooth muscle
hypertrophy and hyperplasia.

15. • If not corrected rapidly, asthma may become more difficult to treat,
as the mucus production prevents the inhaled medication from
reaching the mucosa.
• The inflammation also becomes more oedematous.
• This process is resolved (in theory complete resolution is required in
asthma, but in practice, this is not checked or tested) with beta-2
agonists (e.g., salbutamol, salmeterol, albuterol) and can be aided
by muscarinic receptor antagonists (e.g., ipratropium bromide),
which act to reduce the inflammation and relax the bronchial
musculature, as well as reducing mucus production.

16. Clinical Presentation
• The classical symptoms of asthma are wheeze, shortness of breath, chest
tightness or difficulty breathing and cough.
• These symptoms are typically variable and can be absent for long periods
of time, with possible episodic exacerbations often triggered by factors
such as exercise, allergen or irritant exposure, cold air or viral respiratory
infections.
• The diagnosis of asthma is clinical and relies on the recognition of a
characteristic pattern or respiratory symptoms and signs in the absence of
an alternative explanation.

17. Features that increase the probability of asthma are:
• More than one of the following symptoms: wheeze, cough, difficulty
breathing and chest tightness
• Episodic symptoms that are worse at night and in the early morning,
and occur in response to certain triggers, e.g. exercise, allergen
exposure, cold air
• Personal history of an atopic disorder or family history of an atopic
(allergic) disorder and/or asthma
• Widespread wheeze on auscultation

18. • Lung function tests are useful in the evaluation of a patient with
asthma to assess the presence, severity and reversibility of the
airflow obstruction.
• On Spirometry an FEV1/FEV ratio less than 0.7 confirms
obstruction.
• In asthmatic patients, there is usually a large bronchodilator
response (typically an increase of at least 12-15% in FEV1) 3, and it
is also typically an abnormally high variability of the peak
expiratory flow.
• A normal Spirometry, particularly if performed when the patient is
asymptomatic, does not exclude the diagnosis of asthma.

19. When does asthma become life threatening?
– Difficulty to catch a breath
– Difficulty talking and concentrating
– Difficulty talking and walking
– Cyanosis of skin especially around the mouth and finger
areas
– Nasal flaring and constant wheeze
– When these signs and symptoms presents, a person should
be aware and are advice to consult with your general
practitioner as soon as possible.

20. Investigations and Diagnosis
Diagnosis of asthma is confirmed based upon various factors:
1. Medical History
2. Family History: If the patient has a family history of asthma or allergies,
they are more likely to also suffer from asthmatic symptoms.
3. Physical Assessment: The patient’s nose, throat and upper airways will
be examined for signs of asthma or allergies. Assessment of the patient’s
respiratory rate and breathing pattern will be carried out in conjunction
with auscultation S & S include: Wheezing (high-pitched whistling
sounds when the patient exhales) Coughing, chest tightness, Shortness of
breath (SOB), A runny nose, Swollen nasal passages.

21. Diagnostic Tests
• The following tests are used to assess the patient’s breathing
as well as to monitor the effectiveness of asthma treatment.
• Lung function tests: Spirometry Peak flow testing
• Other tests:
– Allergy testing
– Bronchoprovocation
– Chest X-ray
– Electrocardiogram (ECG)

22. Treatment
• The goal of the treatment is to control the symptoms, prevent
exacerbations and loss of lung function and reduce associated mortality.
• Drugs used for control of asthma depend on the severity of the disease.
– Short-acting β2-agonists can be used in patients with mild occasional
symptoms.
– Inhaled steroids (oral steroids might be required in severe cases) and
long-acting β2-agonists can be used for long-term control.
– Oxygen, short-acting β2-agonists, inhaled anticholinergic and
systemic steroids are used in acute exacerbations.

23. A. Short-acting beta 2-agonists (quick acting or rescue
medicine):
– These drugs are used best to treat sudden and severe or new
asthma symptoms as they open the airways and relieve
symptoms within 20 minutes and lasts four to six hours.
– It can also be used before physical activity about 15-20
minutes before the time to prevent exercise-induced
asthma.

24. B. Long-acting beta 2-agonists:
– These drugs are not used to for a quick relief of
asthma symptoms, instead they are used to control
symptoms and their effect lasts 12 hours.

25. 2. Mechanical ventilation may be necessary for severe
exacerbations that do not respond to medical treatment.
– Non-pharmacological measures, such as smoking cessation and
avoidance of occupational sensitizers, are also important.
3. Non-pharmacologic management, including asthma
education on inhaler technique and self-monitoring, is
vital.

29. Prognosis
• Asthma is a disease with variable progression and severity of symptoms
over time. The prognosis depends on the severity of the disease and the
degree of control with treatment.
• Some patients can be symptom-free for long periods, whereas a few
patients with severe persistent asthma develop progressive loss of lung
function.
• Death due to asthma is very rare.
• Even though asthma is a reversible disorder, poor lifestyle and lack of
management can lead to airway remodelling that leads to chronic
symptoms, which are disabling.

30. PHYSIOTHERAPY MANAGEMENT
• The majority of patients suffering from asthma will seek
physiotherapy for dyspnoea and hyperventilation.
• Physiotherapists treat asthma in a variety of ways with the aim
to improve breathing technique.
• Physiotherapy techniques for asthma are in addition to
medication and should never be used as a replacement for
prescribed medication, however may reduce the dosage
required.

31. 1. Breathing Retraining Techniques
• Breathing techniques may have more benefit on mild –
moderate asthma.
• The aim of breathing retraining is to normalise breathing
patterns by stabilising respiratory rate and increasing
expiratory airflow.
• Instructions are given from the physiotherapist on how to
complete this technique, with the following components:

32. • Decreasing Breaths Taken (Reducing Respiratory Rate)
• Taking Smaller Breaths (Reducing Tidal Volume)
• Deep Breathing (Diaphragmatic breathing through use of
abdominal muscles and lower thoracic chest movement)
• Breathing through the Nose (Nasal Breathing)
• Relaxation (Relaxed, controlled breathing)
• Decreasing Air Leaving (Decreased expiratory flow through
pursed lip breathing)
• These retraining techniques help control breathing and reduce
airflow turbulence, hyperinflation, variable breathing pattern
and anxiety.

33. Buteyko Breathing Technique:
• The Buteyko breathing technique is another breathing retraining technique;
however it is specific to reducing hyperinflation.
• It was developed based on the theory that asthmatic bronchospasm is
caused by hyperventilation, leading to a low PaCO2 and therefore all
asthmatic symptoms are due to this.
• The narrowed airways induce an “air hunger” causing a switch to mouth-
breathing and an increased respiratory rate leading to hyperinflation.

34. • Buteyko believes that this hyperinflation then also contributes
to bronchoconstriction.
• The Buteyko technique aims to reduce ventilation and
subsequently lung volume, as a treatment for asthma and other
respiratory diseases.
• A qualified practitioner is necessary to train the patient.

35. The Buteyko Technique:
– Breathe normally through the nose for 2-3 mins
– Breathe out normally, close nose with fingers, and hold
– Record number of seconds
– On first need to breathe, release nose and return to nasal
breathing (Control Pause)
– Wait 3 minutes
– Repeat and hold breath for as long as possible (Maximum Pause)

36. • Breathing pattern retraining and relaxed breathing techniques are
two approaches to physiotherapy management of asthma.
• The aim of breathing pattern retraining is to develop a more efficient
pattern of respiration, thereby reducing breathlessness.
• This is usually accomplished by slowing the breathing rate, and
encouraging relaxed, ‘abdominal’ breathing.
• Another potential mechanism for breathing pattern retraining is that
by encouraging a longer expiratory time, the effects of any static/
dynamic hyperinflation may be reduced.

37. • Mild asthmatics can hold their breath for up to twenty seconds,
moderate asthmatics for fifteen seconds and severe asthmatics for up
to ten seconds.
• The aim of this method is to increase the control pause to 60 seconds
and the maximum pause to 2 minutes.
• It is practiced twice a day, with the practitioner there to help with
breath holding and ensure safety.
• Its aim is to reduce minute volume through reduction of respiratory
rate, and increasing carbon dioxide levels through breath holding,
reducing bronchospasm caused by hyperventilation in the asthmatic
patient.

38. 2. Physical Training
• Physical training with asthma is advised when taking the proper
precautions, and should not be avoided. The American College of Sports
Medicine (ACSM) Guidelines provide tips and safety precautions for
asthmatics to exercise safely.
• Physical training should be prescribed by physiotherapists for asthmatics to
increase fitness and cardio respiratory performance, reduce symptoms such
as breathlessness and improve quality of life .
• Breathlessness, chest tightness and wheezing can occur when exercising,
deterring patients from physical exertion.

39. • Fear avoidance can contribute to a further deterioration of
physical health and quality of life, leading to anxiety and
depression.
• It has been shown that maintaining physical training in
asthmatics improves disease symptoms and quality of life,
therefore making it a crucial management strategy.
• A study protocol suggests behaviour change intervention
focussing on increasing participation in physical activity may
exert control over asthma and quality of life.

40. 3. Respiratory Muscle Training
• Hyperinflation in asthma causes increased lung volume,
leading to altered Inspiratory muscle mechanics.
• Inspiratory muscles are shortened resulting in a sub-optimal
length-tension relationship for contraction.
• There is a decreased capacity for tension generation when
breathing, resulting in accessory muscles of inspiration being
utilised.

41. • A breathing device is used which sets up a load to breathe
against.
• During inspiration air is only released if enough effort is used
to force open the valves of the device.
• Respiratory muscles are forced to work harder, increasing their
strength, leading to diaphragmatic breathing becoming easier,
reducing hyperinflation.

42. 4. Removal of secretions
1. Percussions
2. Shaking
3. Vibrations,
4. Postural drainage and
5. Effective coughing

43. • A randomized crossover study examining the ability of
physiotherapy techniques in sputum induction in children and
adolescent patients with Asthma suggested that specific
physiotherapy manoeuvres may facilitate the collection of
mucus, yielding the same amount of sputum as the gold-
standard technique (hypertonic saline).

44. • The study confirms that sputum induction through
physiotherapy manoeuvres is safe in well-controlled asthmatic,
and enables physical therapists to mobilize secretions without
causing bronchospasm in patients.

45. 5. Range of motion exercises
Exercises for patients who need hospitalisation.

46. 6. Education
• About condition
• On use of a bronchodilator and any other medication
• How to prevent chest infection from occurring
• Correct posture in standing and sitting which assists in the
management of asthma attacks by allowing the chest to expand
appropriately and the lungs to function optimally

47. Thank you