ASTHMA

Dr.Sathaporn Kunnathum
19 January 2010
 when you were born you were crying and
everyone around was smiling, live your life
so that when you die, you are smiling and
everyone is around crying.

Anonymous
Current Understanding of Asthma

 A chronic inflammatory disorder of the

airway
 Infiltration of mast cells, eosinophils
and lymphocytes
 Airway hyperresponsiveness
 Recurrent episodes of wheezing,
coughing,chest tightness and
shortness of breath
 reversible airflow limitation
 The Underlying Mechanism
Risk Factors (for development of asthma)

INFLAMMATION

Airway
Hyperresponsiveness Airflow Limitation

Symptoms- (shortness
Risk Factors of breath, cough, chest
(for exacerbations) tightness, wheeze)
Asthma: Pathological changes
Risk Factors that Lead to Asthma Development
Predisposing Factors
 Atopy
Causal Factors
 Indoor Allergens
– Domestic mites
– Animal Allergens
– Cockroach Allergens
– Fungi
 Outdoor Allergens
– Pollens
– Fungi
 Occupational Sensitizers
Contributing Factors
 Respiratory infections
 Small size at birth
 Drugs and Diet
 Strong emotional
expression
 Air pollution
– Outdoor pollutants
– Indoor pollutants
 Smoking
– Passive Smoking
– Active Smoking
 DIAGNOSIS OF ASTHMA

 History and patterns of symptoms

 Physical examination

 Measurements of lung function

 PATIENT HISTORY

 Has the patient had an attack or recurrent

episodes of wheezing?
 Does the patient have a troublesome cough,
worse particularly at night, or on awakening?
 Does the patient cough after physical activity
(eg. Playing)?
 Does the patient have breathing problems
during a particular season (or change of
season)?
 Do the patient’s colds ‘go to the chest’
or take more than 10 days to resolve?
 Does the patient use any medication
(e.g. bronchodilator) when symptoms
occur? Is there a response?
If the patient answers “YES” to any of
the above questions, suspect asthma.
 Physical Examination

Wheeze -
Usually heard without a stethoscope

Dyspnoea -
Rhonchi heard with a stethoscope
Use of accessory muscles

Remember -
Absence of symptoms at the time of examination does not
exclude the diagnosis of asthma
 Diagnostic testing

Diagnosis of asthma can be confirmed

by demonstrating the presence of
reversible airway obstruction using
Spirometry.
Peak flow meter.
 FEV1
ForceExpiratoryVolumein1second
FVC
ForceVital Capacity

(spirometry)
Peak Flow meter
 Bronchodilator Test

 Peak Flow before and after bronchodilator 15 min

 FEV1 > 12 % is asthma
 PEFR > 15 % is asthma

•Salbutamol inhaler 2 puffs PEFR increase

•wait 15 minutes
390-300
300
PEFR =300 L/min PEFR =390 L/min
= 30%
 GINA 2006 •Day symptoms
•Night symptoms
•Reliever
2006
Assessing asthma control •PEFR
•Exacerbation
•Limitation of activity

•Controlled
•Partly controlled
Treating to achieve asthma control •Uncontrolled

1. B2-agonist prn
2. ICS
3. ICS (low dose) + LABA
4. ICS (high dose) + LABA
5. ICS (high dose) + LABA + prednisolone

Monitoring to maintain control

 Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled
(All of the following) (Any measure present in any
week)
Daytime symptoms None (twice or less/week)More than twice/week Three or more
features
Limitations of activities None Any of partly controlled
asthma present
Nocturnal None Any
symptoms/awakening
Need for reliever/ None (twice or less/week)More than twice/week
rescue treatment
Lung function (PEF or Normal < 80% predicted or personal
FEV1)‡ best (if known)
Exacerbations None One or more/year* One in any week†

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
† By definition, an exacerbation in any week makes that an uncontrolled asthma week.
‡ Lung function is not a reliable test for children 5 years and younger.
 Pharmacological therapy

 Relievers  Controllers
 Inhaled fast-acting  Inhaled corticosteroids
β 2-agonists
 Inhaledlong-acting
β 2-agonists
 Oral anti-leukotrienes
 Oral theophyllines
 Simplified asthma treatment
Asthma Patient
Total control
No day symptoms
No night symptoms
No rescue medication
Assess Control No ER visit
PEFR >80%

ICS 500ug/d
+
Treatment ICS 500ug/d Other controller
 Goals to Be Achieved in Asthma
Control
 Achieve and maintain control of symptoms
 Prevent asthma episodes or attacks
 Minimal use of reliever medication
 No emergency visits to doctors or hospitals
 Maintain normal activity levels, including exercise
 Maintain pulmonary function as close to normal as
possible
 Minimal (or no) adverse effects from medicine
 Inhalation devices you can use

Dry Powder Spacer

Inhaler Metered Dose
inhaler
Age-wise selection of inhaler devices

 < 3 years – MDI + Spacer + Mask or nebulisers

 3 – 5 years – MDI + Spacer + Mask or

Rotahaler

 5 – 8 years – Rotahaler or MDI + Spacer

 > 8 years – Rotahaler or MDI + Spacer

 Key Messages

 Asthma is a common disorder

 It can happen to anybody
 It is not caused by supernatural forces
 Asthma is not contagious
 It produces recurrent attacks of cough with or
without wheeze
 Between attacks people with asthma lead
normal lives as anyone else
 In most cases there is some history of allergy
in the family.
 Key Messages

 Asthma can be effectively controlled, although it cannot

be cured.

 Effective asthma management programs include

education, objective measures of lung function,
environmental control, and pharmacologic therapy.

 A stepwise approach to pharmacologic therapy is

recommended. The aim is to accomplish the goals of
therapy with the least possible medication.