Seminar on Management of Bronchial Asthma

Seminar on;
Management of Bronchial Asthma
Prepared by Dr. Atinkut Abesha.
Moderator Dr. Girma (MD, Assistant professor of I. Medicine)
Date: 27/04/2014 E.C
Management of Bronchial Asthma; BY: Atinkut A. (Medical Intern) 1

Objectives
To know about definition of Asthma
To know about pathophysiology of Asthma
To know approaches to management of B. Asthma

Outlines
Introduction
Etiology and Risk factors of Asthma
Pathophysiology of Asthma
Classification of Asthma
Clinical presentations of Asthma
Diagnosis
Management of Asthma

Case scenario 1
Mr. X a 21 years old male patient presented with SOB, chest
tightness, and dry cough of 01 week duration which was
exacerbated during cold weather. Those symptoms came
1x/month. Associated to this he has hx of sneezing, rhinorrhea
and nasal congestion. He has also recurrent hx of itching
sensation around his nose. He has also family hx of Asthma,
DM and HTN from his father. He did not took any medication
before for those symptoms.
4
Management of Bronchial Asthma; BY: Atinkut A. (Medical Intern)

Case scenario 1… Cont
P/E: G/A: ASL
V/S: BP= 110/70, PR= 105, RR=28, T=36.9, SPO2= 91% with ATM
R/S: scattered wheezing on posterior chest bilaterally
N/S: COTPP
Investigation: CBC: WBC= 9.2, N=78%, E=8.1, Hgb=12.1, Hct=37.9,
MCV=84.2, PLT= 274
CXR=Unremarkable
Mgt: Salbutamol 6 PUFF PRN, prednisolone 40 mg/day for 01 week
5

1. What will be the possible Dx (Diagnostic flow chart)?
2. How do we assess the patient (Based on parameters)?
3. Where is her step of treatment
4. How do we manage the patient (Step up and Step down approach)?
5. Comment on the treatment which was given to the patient?
6

Case scenario 2
Ms. Y: a 28 years old known Asthmatic patient for the last 06
months duration who was on Budesonide: Formotelol
(Symbicort) which was taken 2 PUFF twice daily and
Salbutamol 6 PUFF PRN presented with exacerbation of SOB
of 02 day duration. Associated to this she has hx of whitish
productive cough, audible breath sound, chest tightness, LGIF
of the same duration. She also had hx of night time wake up
1x/wk . She has also previous hx of similar attack 02/month.
Othewise no hx of DM and HTN
7

P/E: G/A: ASL INO2
V/S: BP= 120/70, PR= 110, RR=30, T=36.8, SPO2= 96% with 4L &
82%ATM
R/S: diffuse wheezing on posterior chest bilaterally
N/S: COTPP
Investigation: CBC: WBC= 17.21, N=94%, E=1.6, Hgb=16.7, Hct=48.9,
MCV=92.3, PLT= 280
CXR= Hyper inflated lung
8

1. What will be the possible Dx (Diagnostic flow chart)?
2. How do we assess the patient (Based on parameters)?
3. Where is her step of treatment
4. How do we manage the patient (Step up and Step down approach)?
5. Comment on the treatment which was given to the patient?
9

Introduction… Def…
Asthma; a disease characterized by episodic airway
obstruction and airway hyperresponsiveness usually
accompanied by airway inflammation

Introduction… Epidemiology…
∼241 million people affected globally (Worldwide; 4.3%)
More prevalent among children (8.4%) than adults (7.7%)
Childhood M: F; 2:1, but Adulthood greater prevalence in
women
 Mortality rate globally 0.19/100,000

Etiology and Risk factors of Bronchial Asthma
Allergen exposure
Occupational exposure
Air pollution
Infections
Tobacco
Obesity
Diet
Irritants
High intensity exercise in elite athletes

Pathophysiology of Bronchial Asthma
Histology of Bronchus;
Mucosa
Muscularis mucosae
Submucosa
Cartilaginous layer
Adventitia

ghyjkv

.

Airway hyperresponsiveness is a hallmark of asthma;
Bronchoconstriction
airway inflammation, and
Mucous impaction

Classification of Bronchial Asthma
Intermittent
Persistent Based on Severity (symptoms)
Mild
Moderate
Sever
Childhood onset Asthma Based on age of Onset
Adult onset Asthma

Clinical Presentations of Bronchial Asthma
History of respiratory symptoms
Wheeze
Chest tightness Vary over time and
in intensity
Shortness of breath
Cough
Variable expiratory airflow limitation

Diagnosis of Bronchial Asthma
History
Physical Examination
Investigation
 Pulmonary Function Tests
Eosinophil Counts
IgE
Skin Tests
Radioallergosorbent Tests
Exhaled Nitric Oxide

Diagnosis of B.Asthma…Investigation
Spirometry;
Assess how well the lungs work by measuring lung volume,
capacity, rates of flow, and gas exchange
Confirms Variable Expiratory Air flow limitations
FEV1, FEV1/FVC
Diurnal PEF variability
Lung function after treatment

Spirometry;
Helps to differentiate Obstructive or Restrictive Lung diseases
Characteristics Obstructive Restrictive
FEV1 <80% of the predicted
normal
<80% of the predicted
normal
FVC but to a lesser extent
than FEV1
<80% of the predicted
normal
FEV1/FVC <0.7 >0.7

Spirometry;
Clues b/n obstructive lung diseases
Characteristics Spirometry for Asthma Spirometry for COPD
FEV1 Increases by 12% after BD Doesn’t Increase by 12% after
BD
FVC May or May not be reduced Always Reduced
FEV1/FVC Less than 70% Less than 70 %
Serial Spirometry Vary or remain similar over time Deterioration in values in time
22

Spirometry;
Once the diagnosis of asthma has been made, the main role
of lung function testing is for the assessment of future risk.
It should be recorded;
 At diagnosis
3–6 months after starting treatment
Periodically thereafter.

Diagnosis of B.Asthma…Diagnostic flowchart
Patient with respiratory symptoms.
Are they typical of Asthma?
Detailed Hx & P/E for Asthma.
Are they supports Asthma Dx?
Is patient already taking asthma controller
treatment?
Perform Spirometry /PEF with reversibility test.
Is result support Asthma Dx?
Treat for Asthma
No Further Hx & Test for
alternative DX
Treat for
Alternative Dx
Y
e
s
No
- Arrange other tests
-Confirm Asthma Dx
Consider trial of
treatment for most
likely Dx or refer for
further investigations
yes
yes
No
N
o
No
Y
e
s
Yes
No
yes
Dx
step
es
for
Cont
rolle
r t/t

Diagnosis of B.Asthma…Diagnostic flowchart
Is patient already taking asthma controller treatment?
Variable
respiratory
symptoms and
variable airflow
limitation
Variable
respiratory
symptoms but no
variable airflow
limitation
Few respiratory
symptoms, normal
lung function and no
variable airflow
limitation
Persistent shortness
of breath and
persistent airflow
limitation
1 2 3
4
Diagnosis of
asthma is
confirmed
Assess the level
of asthma
control
Consider
repeating
Spirometry
1. If FEV1 is >70% predicted,
stepping down &reassess
after 2-4wks
2. If FEV1 is <70% predicted,
stepping up for 3 months
1. Symptom emerge
and lung function
falls: asthma is
confirmed…. Step Up
Consider stepping
down
2. ceasing
controller if no
change in
symptoms or lung
function (1 year
follow up)
Consider
stepping
up for 3
months
25

Assessment of Asthma
Asses Asthma control
Asses Asthma severity
Asses Comorbidity
Asses treatment issues

I. Assessment of Asthma control
Asthma control is assessed in two domains:
Symptom control (In the past 4 weeks)
Frequency of daytime asthma symptoms (>2/wk)
Any night waking due to asthma
For patients using SABA, frequency of SABA use (>2/wk)
Any Activity limitation due to Asthma
Well controlled, Partly controlled, Uncontrolled

I. Assessment of Asthma control
Risk of adverse outcomes (Exacerbations)
≥1 exacerbation in the previous year
Socioeconomic problems
Poor adherence
High SABA use
Incorrect inhaler technique
Low Lung function test
Exposure
Type II inflammatory mediators like blood eosinophilia
Other medical conditions

II. Asthma severity
Mild
Moderate
Sever

III. Comorbidities
Contribute to symptoms and poor quality of life, and
sometimes to poor asthma control
Rhinitis
Rhinosinusitis
GERD
Obesity
OSA
Depression
Anxiety Management of Bronchial Asthma; BY: Atinkut A. (Medical Intern) 30

IV. Treatment issues
Inhaler technique
Written asthma action plan
Patient’s attitudes and goals for their asthma and medications
Document the patient’s current treatment step

Management of Bronchial Asthma
Goals of management
To achieve good symptom control
To minimize future risk of asthma-related mortality
To minimize exacerbations
To minimize persistent airflow limitation
To minimize side-effects of treatment

In order to achieve the above goals;
Non pharmacological treatment
Pharmacological treatment

I. Non pharmacological treatment
Reducing triggers
Treating modifiable risk factors
Vaccination
Bronchial thermoplasty

II. Pharmacological treatment
Bronchodilators (β2 -agonists, anticholinergics, and theophylline)
Controllers (Anti-Inflammatory/Antimediator); Costicosteroids
35

II. Pharmacological treatment

For adults and adolescents step Up/Down approach

Patients should be seen 1–3 months after starting treatment
Every 3–12 months thereafter.
After an exacerbation, a review visit within 1 week should be
scheduled
Stepping down treatment when;
Asthma is well controlled for 2–3 months and
Lung function has reached a plateau
N.B. Complete cessation of ICS is associated with a significantly
increased risk of exacerbations

It involves a continual cycle that involves assessment,
treatment and review by appropriately trained personnel

References
Harrison’s principles of Internal Medicine 21st edition
GINA, 2022 updated
Up to date 2018

Thanks A Lot!!!
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Seminar on Management of Bronchial Asthma

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