Asthma Lecture For Medical Students

2. • Reactive Airways Disease.
– (Top) Peribronchial thickening (white circles) seen en face shows small
donut-like rings in periphery of lungs, not normally seen.
• Contained in yellow circle are thickened bronchial walls seen in profile with a
"tram-track appearance.
– (Bottom) Close-up of left lower lung in same patient shows more donut
shaped thickened bronchial walls. (yellow arrows)

3. DEFINITION
• A chronic inflammatory disorder
• causing hyper- responsiveness of airways to certain stimuli,
• resulting in recurrent airflow obstruction,
• presenting as
• wheezing,
• breathlessness,
• chest tightness, &
• coughing;
• completely or partially reversible with bronchodilator or spontaneously
resolving
CLASSIFICATION
• Pathophysiological Classification
• Clinical Classification
• Classification on the bases of control

6. • 90% of all asthma,
• common in children,
• 80% with documented allergy.
Extrinsic
OR atopic
asthma:
• 10% of all asthma,
• common in women after 30,
• follows URTI
• symptoms persist, & difficult to
treat.
Intrinsic OR
non-atopic
asthma:

9. Special variants:
• Exercise induced:
• Almost all asthma patients experience it.
• Some patients have it as a precipitant.
• Reduction of FEVj ≥ 10% is diagnostic,
• Cough variant:
• Chronic cough & sputum eosinophilia.
• Mostly in young at night.
• Drug induced:
• Aspirin,
• propranolol,
• timolol
• may induce in some patients.
• Occupational:
• Agents inhaled in occupational settings-
• farmer,
• cigarette manufacturer,
• bakery worker, etc.
• Seasonal.

10. Intermittent:
• ≤ 2 nocturnal symptoms in a month.
• Between episodes, patient is symptom-free &
• PFT is normal.
Persistent:
• Frequent attacks, >2/month.
• In between, patient may or may not be symptom-free &
• PFT is abnormal except in mild variety.
• Severity of persistent asthma:
• Mild:
• > 2 times/month, &
• PEFR or FEVj is usually <80%-65%.
• Moderate:
• Almost daily attack, &
• PEFR/FEV1 is <65%-50%.
• Severe:
• Dyspnea continuously for ≥ 6 months, &
• PEFR or FEV1 <50%.

11. Acute exacerbation:
• Loss of control of any class or variant may cause mild to life-
threatening condition:
• Mild:
• Patient is dyspneic but
• can complete sentences.
• Moderate:
• Patient is dyspneic &
• cannot complete sentence in one breath.
• Severe:
• Patient is severely dyspneic,
• talks in words &
• may be restless, even unconscious

14. Classification on Basis of Control
• important & relevant for management of asthma.
• On basis of control, asthma can be classified as
• (i) controlled,
• (ii) partly controlled, &
• (iii) uncontrolled
PRINCIPLE OF DIAGNOSIS
• Clinical criteria:
• Cardinal feature of asthma-
• paroxysmal respiratory distress,
• recurrent cough,
• wheeze,
• chest tightness,
• recurrent attacks due to multiple stimuli.

15. Pulmonary function tests (PFT):
• important parameters in spirometry include
• PEFR,
• FEV1,
• FVC &
• FEV 25-75.
• In asthma,
• FEV/FVC is <0.8 (normal, 0.8-1).
• FEV1 is commonly used for assessing severity of asthma.
• FEV 25-75
• effort independent & probably more sensitive indicator of airway
obstruction.
• PEFR
• can be measured with peak expiratory flow meter, while
• for other parameters spirometer is required.
• It may be used as a diagnostic tool as well as monitoring of treatment.

16. Abnormality in PEFR suggestive of asthma include:
• A diurnal variation of >20%, ≤ 80% of predicted, & improvement of ≥ 20% after
bronchodilator therapy.
Bronchodilator reversibility test:
• done to differentiate obstructive defect from restrictive defect &
to differentiate asthma.
• Reversibility can be found out by FEV1 before & 30 minutes after administration of
β2-agonist aerosol.
• An ↑ of >12% in PEFR or FEV1 after aerosol therapy is strongly suggestive of
asthma.
• Failure to respond, however, does not exclude asthma.
Variability tests:
• PEFR is usually lowest in morning (6.00 AM) & highest in afternoon (6.00 PM) in
asthmatic patients.
• PEFR measurements on morning & afternoon (for-1 wk) before treatment can
establish diurnal variability,
• ↑ in variability of >20-30%, on an average, indicate ↑ bronchial responsiveness &
worsening asthma.

17. Laboratory criteria:
• Sputum eosinophilia,
• ↑ eosinophil count in blood
• Blood gas analysis, pH
CXR:
• Shows bilateral symmetric air trapping.
• Patches of atelectasis of various sizes due to mucous plaque is not
unusual.
• Extensive areas of collapse, consolidation suggest an alternative
diagnosis.
• X-ray is also done to exclude TB.
• CXR may be normal in asthma.
Allergy test:
• Skin test & RAST (radioallergosorbent test) have limited usefulness,
since role of desensitization therapy is not fully established.

18. D/D
Pulmonary
tuberculosis,
Bronchiolitis,
Bronchiolacia or
Tracheomalacia,
Foreign body
aspiration,
Hypersensitivity
pneumonitis,
Cystic fibrosis,
Recurrent
pneumonia,
GERD.

19. MANAGEMENT PLAN
•Management goal is to achieve clinical
control. GINA revised guideline-Rule of '2':
•Day time symptoms <2/wk
•Nocturnal symptoms <2/mo
•Number of reliever drug <2/yr (salbutamol
canister)
•No exacerbation
•Normal or near N lung function
•No limitation of daily activities

20. Management of Asthma at Home
•First aid for asthma-"Rule of 5"
•Ensure patient is sitting comfortably
upright, be calm, & reassuring
•Give 5 puffs of reliever inhaler with spacer
direct through mouthpiece
•Wait for 5 minutes
•If no improvement, give another 5 puffs
•Repeat process for 5 times; if little/no
improvement, transfer to hospital with
puffs every 5 minutes

21. Traffic zone system of control:
Green zone:
• Indicated all is clear,
• PEF 80-100%, <15% variability,
• minimal symptom-patient has to continue treatment
Yellow zone:
• Indicated caution 60-80%,
• 5-25% variability,
• asthma symptom may occur-intensification/stepping up of maintenance
Red zone:
• PEF <60% &
• symptom at rest-
• immediate β2-agonist use,
• follow yellow zone if improve or report to emergency department.

22. TREATMENT
• Treatment of Mild Acute Asthma
• Inhaled salbutamol
• 1 puff stat, another one after 5 minutes;
• then 1-2 puffs 3-4 hourly for the next 12-24
hour. Spacer is preferable.
• If inhaled salbutamol is not available, give
oral salbutamol 0.2-0.4 mg/kg/d, 6-8 hourly
for the next 12-24 hour.
• If no improvement after 24 hour,
• advise for hospitalization for further
management.

25. Dehydration,
• if any, must be corrected by dextrose saline.
• Potassium may be given if hypokalemia develops.
• Usually, > 1-1.5 times maintenance fluid should be given.
• Care should be taken not to over-hydrate the patient.
Routine administration of antibiotics
• is not needed, but if
• consolidation on chest X-ray,
• blood neutrophilia, or
• presence of coarse crepitations or bronchial breath sounds,
• give antibiotics, e.g; erythromycin or amoxicillin

26. Chest X-ray
• should be obtained
• in all severe cases or
• when mediastinal emphysema,
• Pneumothorax, or
• pneumonia is suspected.
Sedation is hazardous.
• Tranquillizers, morphine & other opiates are contraindicated because of
their depressant effect on respiratory center.
Rescue steroid therapy:
• During step care management, patient may lose asthma control. at any
step suddenly, for example, due to viral RTI.
• No stepping up is required prior to it. Patient should follow the existing
step after ending the rescue course.
• Oral prednisolone 1-2 mg/kg/d in single morning dose or 2 dd doses for
3-14 days should be given. No tapering of this dose is needed.

27. PREVENTION
• Avoid triggering factors (ASTHMA), i.e.,
• Allergens
• pollen,
• dander,
• dust,
• fungal spore
• Sports
• exercises,
• games,
• traveling
• Temperature
• cold weather,
• wet, windy weather),
• Heredity
• environmental factors,
• Mites,
• Anxiety
• stress, worries
• Desensitization is not very effective, may sometimes be harmful.

28. Clinical
features
Mild
intermitten
t
Mild
persisten
t
Moderate
persistent
Severe
persistent
Days with
symptoms
≤ 2 wk 3-6/wk Daily Continual
Nights with
Symptoms
≤ 2/ mon 3-4/mon > 5/mon Frequent
PEFR or FEV, ≥ 80 % ≥80% > 60-80 % ≤ 60%
PEFR
variability
< 20 % 20-30 % > 30 % >30%

30. Mild Moderate Severe/life-threatening
episode
Symptoms
Physical exhaustion No No yes
Talk in Sentences Phrases Words/can’t talk
Feeding Able to feed
Feed with difficulty
Too breathless to feed
Signs
Consciousness ± agitated Usually agitated Agitated to drowsy
Accessory muscle use:
sternocleidomastoid
retractions
No Yes Usually prominent
Plus(/min) <100 100-160 > 160
cyanosis Absent Absent Likely to be present
Wheeze
End
expiratory
Throughout
expiration
Expiration + inspiration may
be silent chest
PEFR/FEV1 > 60 % 40-60 % < 40 %
Pulses paradoxus N may be present 20-40 mmHg
SaO2( pulse oxynetry) > 95 % 95-91 % < 91%

31. Level of Asthma Control
Characters Controlled ( all of
the fol;)
Partly controlled
( any measure
present in any
wk)
Uncontrolled
Daytime
symptoms
None ( twice or
less/wk)
> Twicw/wk
Limitation of
activities
None Any 3 or more
Nocturnal of
activites
None Any Or more features
of partly
need for reliever
/rescue
None ( twice or
less wk)
> Twice /wk Asthma present
Lung function
(PEFR/PEV1)
Normal < 80% predicated
or personal best
Controlled
asthma present

32. Scoring system for step care
management:
Do you have dyspnea everyday? Score
Do you have nocturnal attacks of
dyspnea >2 times/month? Yes = 1 No = 0
Have you suffered from dyspneic
attacks severe enough to necessitate
steroid tablets or injection,
nebulization, Inj. aminophylline or
hospitalization?
Yes = 1 No = 0
Do you have persistent dyspnea for
last6 months or more or are you
taking steroid tablets (prednisolone
etc.) for any 1 year or more?
Yes = 1 No = 0
Is patient's baseline (asymptomatic
stage) PEF ~60% of predicted value?
Yes = 1 No = 0
Total score 7-0

34. Step detection
Children :55 years >5 year
Score Recommended step Score Recommended step
0 Step I 0 Step I
1 Step II 1 Step II
2 Step III 2 Step III
3-6 Step IV 3 Step IVA
4 Step IVB
5-7 Step V

35. Long term management of Asthma
step care management
step care plan for children < 5 yrs
Childhood asthma Medication Adult asthma
Step I As per need salbutamol inhaler Step I
Step II Full-dose cromolyn or nedocromil
Step II
Step III low-dose ICS
Step IV High-dose ICS Step III
Step VA High-dose ICS + lABN
theophylline
Step IV
Step VB Step V + ora; corticosteroid Step V

36. Step I Step II Step III Step IV Step V
Asthma education and Environmental control
As need rapid acting β₂-agoni
Controller
option
Slect one Slect one Add one Add one/more
Low dose ICS
Low dose ICS +
LABA
Medium/high
dose ICS+ LABA
Oral
glucocorticostero
id icosteroid
Leukotriene modifier (
receptor
antagonist/synthesis
inhibitor
Medium/high
dose ICS
Leukotriene
modifier
Anti-IgG
Low dose ICS
+ leukotriene
modifier
Sustained
release
theopathyline
Low dose ICS
+ Sustained
release
theopathyline
Step care plan for > 5 yrs & adult

37. A 9 yr old boy presents with cough,dyspnea, restlessness & sweating.
His PR = 105/min,RR =45/min , chest is hyperinflated with ↓
movements & hyperresonent percussion note. On auscultation air
entry is bilaterally ↓ & there are widespread expiratory ronchi.
What is the
diagnosis?
Write down 2
imp;
investigations in
this case?
Give 2 common
complications of
this condition?
Write down outline of management of this child?