Asthma is a chronic inflammatory disorder of the airways causing airflow obstruction
and recurrent episodes of
wheezing,
breathlessness,
chest tightness and
coughing.
Chronic inflammatory airway disease associated with increased airway responsiveness and reversible airway obstruction.
It can present at any age; majority of cases diagnosed in childhood
Most of them become asymptomatic by adolescence
Disease severity rarely progresses; patients with severe asthma have it at the onset.
FACTORS EFFECTING ASTHMA:
The inside lining of the airways becomes red and swollen (inflammation)
Extra mucus (sticky fluid) may be produced
The muscle around the airways tightens
(bronchoconstriction)
DIAGNOSIS:
Pulse oximetry and ABG analysis
Chest Xray
Blood Test
Peak Flow meter + Spirometry- PEFR + FEV1 decrease
PEFR + FEV1 increase >15% after β agonist inhalation
Skin Testing
4. Chronic inflammatory airway disease associated with
increased airway responsiveness and reversible airway
obstruction.
It can present at any age; majority of cases diagnosed
in childhood
Most of them become asymptomatic by adolescence
Disease severity rarely progresses; patients with severe
asthma have it at the onset.
4
5. 5
The inside lining of the airways becomes red and swollen
(inflammation)
Extra mucus (sticky fluid) may be produced
The muscle around the airways tightens
(bronchoconstriction)
14. Mechanism:cause bronchial smooth muscle relaxation by
decreasing calcium, opening potassium channels, inhibiting
myosin light chain kinase (MLCK) and stimulating myosin light
chain phosphorylase(MLCP)
Short acting drugs :Onset of action is 5 minutes,duration
of action (4-6 hrs) & hence are drug of choice for acute attack
Long acting drugs:Duration of action (12 hrs)& hence at BD
doses used for prophylaxis
Ultra long acting drugs : duration of action is 24 hrs & hence
used at OD doses for prophylaxis of asthma
Side effects :Tremors are most common due to β2 receptor
stimulation in skeletal muscles
Other-palpitations, QT prolongation
Beta-2 Agonists
17. These drugs mainly cause dilation of large airways
Less effective than beta-2 agonists as they inhibit only the
cholinergic reflex component of bronchoconstriction
These drugs are not approved by FDA but used off label in
patients not responding to or intolerant to β2 agonists
Combined with β2-agonists in treating acute severe asthma
Anticholinergics
18. Ipratropium : short acting (6 hrs) & hence can
be used for an acute attack of bronchial
asthma
Oxitropium: Intermediate acting & can be
used in nocturnal asthma
Tiotropium : longest acting(24 hrs) & used in
long term prophylaxis in combination with
corticosteroids
Anticholinergics Contd…
19. Drugs include :
Theophylline, Aminophylline, Theobromine
Mechanism :
Act by inhibiting Phosphodiesterase which is involved
in breakdown of cAMP & by blockade of adenosine
receptors
Inhibition of phosphodiesterase in lymphocytes gives
additional anti-inflammatory effect
Methylxanthines
20. Theophylline can be used by oral route at a dose of 8
mg/kg BD for persistent asthma along with inhalational
corticosteroids
Aminophylline can be used by I.V route with a loading
dose of 6mg/kg followed by 0.5 mg/kg/hr for
treatment of Acute attack of asthma
Methylxanthines Contd…
Theophylline has a low therapeutic index and hence
therapeutic monitoring is done to maintain plasma
concentration within range i.e 5-15 mg/L
21. These are potent anti-inflammatory drugs & also
decrease bronchial hyperactivity & mucosal edema.
Mechanism: Arachidonic acid (AA) is released
from the membrane phospholipids with the help of
enzyme phospholipase A2 that is inhibited by
corticosteroids. AA is converted to PG and TX by
cyclooxygenase and to LT with the help of enzyme
5-lipooxygenase (5 LOX). Thus, these mediators are
not generated when corticosteroid therapy is initiated
Corticosteroids
22. Steroids are used if patient has to use SABA more than 2
times a week for symptomatic relief
Systemic steroids have a lot of adverse effects,
therefore are reserved for resistant severe chronic
asthma and in status asthmaticus
Hydrocortisone( 100 mg bolus) is I.V. Steroid of choice as
it is fastest acting systemic steroid
Oral prednisolone can be used for persistent asthma
Corticosteroids
23. Inhalational corticosteroids are drug of choice for
persistent asthma
Corticosteroids Contd..
Beclomethasone dipropionate 200-400 g BD
Flunisolide 25 g BD
Budesonide 200-400 g BD
Fluticasone propionate 100-250 g BD
Ciclosenide 40 – 160 g OD
24. Sodium cromoglycate and nedocromil prevent the
degranulation of mast cells by trigger
stimuli indicated only for prophylaxis of bronchial
asthma given by inhalational route.
Ketotifen has antihistaminic action apart from mast
cell stabilizing property and is specially indicated for
patients with multiple disorders (atopic dermatitis,
perennial rhinitis, conjunctivitis etc.).
Mast cell stabilizers
25. Omalizumab is a monoclonal antibody against
IgE and is indicated to prevent the attack of
bronchial asthma in patients not responding to
combination of long acting β2 agonist and a
high dose of inhalational steroid. It is
administered by Subcutaneous route
Drug inhibiting IgE Action
26. Asthma medications can be inhaled (breathed in) or taken
orally (swallowed).
Most people use inhaled asthma medication because:
Medication goes directly to the lungs
Inhalers need to be used correctly to ensure maximum
benefits are achieved.
This means that:
Asthma improves more rapidly
Better control is maintained
Less medication is needed
Fewer side effects are experienced
26
28. Acute asthmatic attack not responding to routine
treatment & β2 agonist, life threatening condition
Precipitated by:
Acute respiratory infection
Abrupt cessation of steroid therapy
Pharmacological stimuli/allergens
Acute emotional stress
29. Hydrocortisone Hemisuccinate 100mg iv stat 4-8 hourly
infusion (take 6 hours to act)
Nebulized salbutamol (2.5-5mg) + Ipratropium Bromide
(0.5mg)
High flow humidified O2
Salbutamol/Terbutaline 0.4mg S.C/I.M
Intubation and mechanical ventilation
Antibiotics
Saline + Sod. Bicarbonate
30.
31. Pretreatment before exercise-
Inhaled beta2-agonists- prevent EIB in more than 80
percent
SABA use may be helpful for 2–3 hours
LABAs can be protective up to 12 hours
Leukotrine receptor antagonist can attenuate EIB in up to
50 percent of patients
Cromolyn or nedocromil taken shortly before exercise is
an alternative
32. Attempts made to improve lung function preoperatively
Short course of oral systemic corticosteroids may be
required
For patients who have received oral systemic
corticosteroids during the past 6 months and for pts on a
long-term high dose of ICS
100 mg hydrocortisone every 8 hours i.v during the
surgical period & reduce dose rapidly within 24 hours after
surgery
33. Asthma increases risk of preterm birth, IUGR and
perinatal mortality.
NEVER WITHHOLD TREATMENT
Monitoring of asthma status during prenatal visits
Albuterol is the preferred SABA because it has an
excellent safety profile
ICS are the preferred treatment for long-term control
medication
Budesonide is the preferred ICS because more data are
available
36. METERED DOSE INHALER
1. Take off the cap.
Shake the inhaler
well.
2. Breathe out
though your
mouth.
3. Place the inhaler
between your lips. As
you start to breathe in,
press the top end of
the inhaler and keep
breathing in steadily
and deeply.
4. Remove the inhaler
from your mouth. Hold
your breath for 10
seconds or as long as you
find comfortable.
Breathe out.
37. The Spacer is a holding chamber which can be attached to
the Metered Dose Inhaler.
1. Assemble the
Spacer by pushing
the notch of one
half into the slot
of the other half.
2. After shaking the
inhaler well, fit it
into the Spacer.
3. Breathe out
through your
mouth. Then close
your lips around the
Spacer.
4. Press the top
end of the
inhaler. Then,
breathe in deeply
though your
mouth.
SPACER
38. Dry Powder Inhalers
1. Insert the
transparent end of
the Rotacap into the
raised square hole of
the rotahaler.
2. Hold the top of the
Rotahaler firmly with
one hand. Rotate the
base until the capsule
breaks.
3. Breathe out through
your mouth. Then,
placing the Rotahaler
between your lips (as
shown), breathe in
though your mouth as
deeply as possible.
4. Remove the Rotahaler
from your from your
mouth. Hold your breathe
for 10 seconds or as long as
you find comfortable.
Breathe out.
39. Attach the hose and mouthpiece to the
medicine cup
Place the mouthpiece in your mouth.
Breathe through your mouth until all the
medicine is used, about 10-15 minutes.
Wash the medicine cup and mouthpiece with
water, and air-dry until your next treatment
NEBULISERS
2 types: Jet nebulisers
Ultrasonic nebulisers
40.
41. INDICATEROL:
Inhaled once-daily β2 agonist
Onset of action faster than salmeterol
Duration of action ~ 24 hrs
Has been approved only for COPD
Clinical trials in asthma underway to test safety and
efficacy of once-daily combination of indacaterol
with mometasone
42. Mapracorat: Selective glucocorticoid receptor agonist that
targets receptors for inflammation only & is devoid of
systemic side effects
Abediterol: Ultra LABA under trial for bronchial asthma
prophylaxis
Recently MgSo4 by I.V. and inhalational route has been
tried for acute severe asthma.
Recent advances Contd…
46. Catheter introduced through a
bronchoscope
It delivers thermal energy to the
airway wall to reduce excess
smooth muscle
Increases symptom-free days,
improves PEFR and reduces the
use of reliever medicines.
FDA approval obtained in 2010 for
treatment of severe asthma.
47. Influenza causes significant morbidity and mortality
in the general population, and the risk can be reduced
by annual vaccination. Influenza contributes to some
acute asthma exacerbations, and patients with
moderate-severe asthma are advised to receive an
influenza vaccination every year
Vaccination
49. Patient awareness/education
Efficacy of patient education and parental
awareness has also been shown to be effective in
individual studies from India
Lifestyle Modifications: Regular balanced diet and
avoidance of obesity.
Short acting beta-2 agonists should be used prior to
anticipated exercise, in a patient with exercise-induced
Asthma, to alleviate symptoms
Alternative System of Medicine:
Yogic breathing exercise technique, Pranayama, was
been shown to reduce in histamine reactivity
49
50. Avoidance of precipitating factors
Avoid dusting when subject is around
Avoid using carpets, stuffed toys, open bookshelves,
smoking, chemical sprays in house. Prefer mosquito nets
to repellants
Food containing allergen to be avoided
Maintain record of daily symptoms
*Involves avoidance of allergens and nonspecific triggers
when Asthma is established.
50
51. Rodrigo et al. Am J Med 1999
n = 1483
Randomized studies, double-blind, controlled
Results:
Pulmonary function improvement
Hospital admission
Stoodley et al. Ann Emerg Med 1999
N = 1377
Slight clinical improvement
No side-effects
52. Asthma is a serious global health problem affecting all
age groups
Despite of better understanding of
Pathophysiology
Presence of reliable diagnostic tools,availability of a
wide range of effective & affordable drugs
Simplified national and international asthma management
guidelines
Asthma remains poorly managed across the globe
SUMMARY
53. Roger walker
Rang and dales
Goodman and Gilman's -12th The Pharmacological basis of
therapeutics
Indian Statistics Index - www.mospi.nic.in
http://www.cdc.gov/asthma -The Centers for Disease Control
and Prevention
National Asthma Education and Prevention Program
http://www.nhlbi.nih.gov/about/naepp/
Allergy and Asthma Network/Mothers of Asthmatics, Inc.
http://www.aanma.org
Global Initiative for Asthma. Global Strategy for Asthma
Management and
Prevention, 2016. Available from: www.ginasthma.org
Pulse oximetry and ABG analysis- HypoxemiaChest Xray- normal or may show increased bronchovascular markingsBlood Test- Raised Absolute eosinophil count + Elevated IgE levels
Skin Testing- may identify causative allergen
Cho JY. Recent Advances in Mechanisms and Treatments of Airway Remodeling in Asthma: A Message from the Bench Side to the Clinic. Korean J Intern Med 2011; 26:367-383