Asthma Bronchiale & Pulmonary Disease during Pregnancy

Febriansyah Darus

Maternal Fetal Medicine Division

Obstetrics and Gynecology Department

RSPAD Gatot Soebroto Jakarta - 2007

Physiological changing in Respiratory tract during pregnancy

Physiological changing in Respiratory tract during pregnancy

Dyspneu pada Kehamilan

The most sympton occur during pregnancy
Hyperventilation Thorax changing

Hyperventilation dyspneu ( increased TV) cb increasing tonus of the respiratory muscle RR stagnant Respiratory activity increased Thorax chaning subcostal angle 68,5 103,5 (aterm) 68 postpartum

Definition Of Asthma
It is reversible chronic obstructive lung disease , characterized by recurrent episodes of wheezing, chest tightness, and coughing alternating with periods of relatively normal breathing. Asthma symptoms can occur spontaneously or may be triggered by allergens, environmental factors, exercise, cold air, infections, and stress.

there is strong evidence that estrogen and progesterone may actually improve lung function and asthma

Progesterone has been shown to suppress the immune system and so in that sense it's protective or helpful. It may reduce the increased inflammation that's occurring. both progesterone and estrogen have been found to reduce constriction of the airways and relax the bronchial smooth muscle in the airways

Asthma
premenstrual
OCPs

menopause menestrual

HRT

pregnancy delivery
Breast feeding

 hormone levels are lower during the premenstrual and menstrual phases--asthmatics have been found to experience an increase Oral contraceptives, which really dampen and smooth out these fluctuations in hormone levels, have been found to improve pulmonary function in some women as well. women move through and into the menopausal period because at this time estrogen, progesterone also rapidly decrease -experience an increase hormone replacement therapy in asthmatic menopausal women have better pulmonary function and less pulmonary obstruction but the increased risk of asthma to HRT on the basis of an observational study in healthy menopausal women

Menstruation and asthma

Asthma is more common in boys than in girls before puberty, but then girls "catch up," suggesting a possible hormonal influence initiating the onset of asthma at menarche asthma symptoms can begin to worsen from three to seven days before the onset of menses(premenstrual asthma), and can last until the bleeding ceases (menstrual asthma) half of cases the woman's attack struck within four days of the start of her menstrual period. one-third of women think their symptoms are worse just before or during menstruation.

Contraceptive pills and asthma

Oral contraceptives, which really dampen and smooth out these fluctuations in hormone levels, have been found to improve pulmonary function in some women as well Some women who use birth control pills may have greater difficulty controlling their asthma. (pill asthma)

Menopause and asthma

Variations in asthma presentation have been observed during the time when serum estradiol levels decreased sharply after a prolonged peak. These findings suggest that these monthly variations in this hormone may influence the severity of asthma in women. The changing hormone levels of menopause may cause some women to develop asthma for the first time; others may experience worsening symptoms

Hormone replacement therapy (HRT) and asthma

hormone replacement therapy in asthmatic menopausal women have better pulmonary function and less pulmonary obstruction but the increased risk of asthma to HRT on the basis of an observational study in healthy menopausal women

Ashtma with pregnancy, delivery,postpartum and breast feeding

Incidence
7 percent of women in their childbearing years 4 percent of all pregnancies . It can cause serious complications for both mother and child if not controlled properly during pregnancy. The good news is that asthma and allergies can be controlled, and when they are, the risks to mother and baby are extremely low.

 allergen exposure --dust mites, cockroaches, and animal danders. pollens, molds, pet dander, house dust mites and cockroaches Other non-allergic substances also may worsen your asthma and allergies. These include tobacco smoke, paint and chemical fumes, strong odors, environmental pollutants (including ozone and smog) and drugs, such as aspirin or beta-blockers (used to treat high blood pressure, migraine headaches and heart disorders). Chronic sinusitis ---the bacteria, toxins, and inflammatory mediators contained in aspirated nasal secretions irritate the mucosa of the lower airways of asthmatic patients, thereby worsening the control of their reactive airway disease Gastroesophageal reflux disease (GERD) is commonly associated with asthma. GERD can cause worsening of asthma by either a vagally mediated mechanism or direct aspiration of acidic gastric contents into the respiratory tree exacerbated by stress and anxiety Aspirin and nonsteroidal anti-inflammatory drugs can cause bronchospasm in some patients with asthma Hormonal factors (ie, menses, use of exogenous hormones by female patients, and hyperthyroidism) also can exacerbate asthma

causes

pathophysiology
The muscles of the bronchial tree become tight the lining of the air passages become swollen, reducing airflow and producing the wheezing sound Mucus production is increased.

Diagnosis and Monitoring

objective measurements are important in evaluation of difficult-to-manage cases objective evidence of airflow obstruction (a tightness in chest and wheezing, shortness of breath and/or coughing) that is reversible either spontaneously or through treatment with a bronchodilator Because both patient and physician may have a poor perception of the severity of the patient's asthma, Spirometric measurement at each office visit or routine use of a peak flow meter by the patient is needed to confirm the effectiveness of the treatment strategy.

You would not consider managing hypertension without a sphygmomanometer, or diabetes without a glucometer accurate and objective assessmentand management of asthma is not possible without a spirometer or peak flow meter

A peak flow meter

at home the convenience and ease of use measure the PEFR (peak expiratory flow rate) by taking a deep breath and then blowing into a tube on the meter as hard and as fast as patient can. every day, sometimes several times a day, and keep track of these rates over time --are compared with charts that list normal values for sex, race, and height.

A spirometer
in a doctor's office gives a more accurate measure of lung function diagnose asthma, classify its severity, and help decide what is the best way to treat asthma done periodically The total volume patient exhale is called "forced vital capacity," or FVC measures the volume of air patient exhale in the first second. (This is referred to as "forced expiratory volume in one second," or FEV1.) Patient will be given a bronchodilator and repeat the measerment

The effect of asthma on pregnancy

specially if untreated well
FETAL

MATERNAL
Increase emergency department visits, Increase hospitalizations, Increase Hyperemesis Increase vaginal hemorrhage and accidental haemorrhage due to severe coughing Increase respiratory failure, Increase high blood pressure and preeclampsia, Increase death..

increased low birth weight, Increase premature delivery, Increase fetal demise
Increase neonatal hypoxemia low newborn assessment scores increased perinatal mortality

NEONATAL

The effect of pregnancy on asthma

Some patients experience an improvement of their symptoms during pregnancy; The exact reason for this is unknown, but the increase in the body's cortizone level during pregnancy may be an important cause of the improvement which can occur. Many women experience less asthma during the last four weeks of pregnancy. This may be due, in part, to the increase of prostaglandin A reported to occur during this time period of pregnancy, or it may be that the "dropping" of the baby in the final weeks of pregnancy takes pressure off the lungs, resulting in easier breathing Others have increased symptoms; . Some women experience gastroesophageal reflux causing belching and heartburn. This reflux, as well as sinus infections and increased stress, may aggravate asthma. Asthma has a tendancy to worsen during pregnancy in the late second and early third trimester. And some see no noticeable change in their asthma at all.

During delivery
Only about 1 in 10 women with asthma have symptoms during delivery. The increase in plasma epinephrine that occurs during labor and delivery may contribute to the absence of asthma symptoms during this critical time period

postpartum and asthma

If you've been pregnant before, you can probably expect your asthma to behave the same way in subsequent pregnancies. Within three months of your baby's birth, your asthma probably will return to the way it was before you became pregnant.

Breastfeeding and asthma

there is some evidence to suggest that breastfeeding may reduce the risk of your baby developing asthma child has a one in ten chance of inheriting the condition from its mother, which rises to one in three if both parents have asthma. But a recent long-term study showed that breastfeeding for the first six months of life significantly reduces the risk of the child's developing allergic breathing problems by age 17, compared to babies who are breastfed for less than six months.

The goal of asthma therapy during pregnancy

It is virtually the same as in non-pregnant patients. The goal is
to prevent hospitalization and emergency room visits as well as lost time at work and chronic disability.

Since the symptoms associated with asthma and allergies can vary from day to day, month to month, or season to season, regardless of pregnancy, treatment plan will be based on the severity of disease and previous experience using specific medications during pregnancy

Prevention
Decrease or control exposure to known allergens and irritants by staying away from cigarette smoke, exposure to pets removing animals from bedrooms or entire houses, and avoiding foods that cause symptoms. Alcohol should be doubly avoided by the pregnant woman with asthma, because it can harm the developing fetus and because it can cause bronchial constriction as it is exhaled through the lungs Allergy desensitization is rarely successful in reducing symptoms

If a patient tests allergic to a specific trigger, allergists-immunologists recommend the following avoidance steps
Remove allergy-causing pets from the house. Seal pillows, mattresses and box springs in special dust miteproof casings (your allergist should be able to give you information regarding comfortable cases). Wash bedding weekly in 130 degrees F water (comforters may be dry-cleaned periodically) to kill dust mites.* Keep home humidity under 50 percent to control dust mite and mold growth. Use filtering vacuums or "filter vacuum bags" to control airborne dust when cleaning. Close windows, use air-conditioning and avoid outdoor activity between 5 a.m. and 10 a.m., when pollen and pollution are at their highest.

Monitoring
The pregnant asthmatic should be monitored carefully and the selection of medications should be reviewed by a specialist. Doctors are very cautious about the use of drugs during the first three months of pregnancy, even though most anti-asthmatic medications are considered safe during pregnancy. The medications do not appear to be associated with increased congenital malformations, nor is there is any evidence that anti-asthmatic drugs (theophylline, beta agonists, cromolyn sodium, or steroids) will adversely affect a nursing infant. the potential risks of asthma medications are lower than the risks of uncontrolled asthma, which can be harmful to mother and baby. As long as the asthma is controlled, the pregnancy and its outcome do not appear to be adversely affected by the mother taking cortisone (steroids) orally or by inhalation. Aerosols and sprays are preferable to oral medication Time-tested older medications are preferred

Self-management of asthma outpatient management of asthma

Teach the patient self-management (Level of Evidence=A; The patient should have good knowledge of self-management. The components of successful self-management are acceptance of asthma and its treatment effective and compliant use of drugs a PEF meter and follow-up sheets at home written instructions for different problems As a part of controlled self-management the patient can be given a PEF follow-up sheet with individually determined alarm limits and the following instructions (Level of Evidence=B; If the morning PEF values are 85% of the patients earlier optimal value, the dose of the inhaled corticosteroid should be doubled for two weeks. If the morning PEF values are below 50 - 70% of the optimal value the patient can start a course of prednisolon 40 mg daily for one week and contact the doctor by telephone.

Treatment Protocol
DIAGNOSIS BASED ON SYMPTOMS & OBJECTIVE ASSESSMENT

ASSESS SEVERITY
MILD MODERATE SEVERE

ENVIRONMENTAL CONTROL AND EDUCATION INHALED SHORT-ACTING BETA2-AGONIST PRN

INHALED CORTICOSTEROIDS

ADDITIONAL THERAPY

New Asthma Treatment Algorithm

Categories of medication
1. "Relievers" (for intermittent symptoms) -short-acting 2-agonists -ipratropium (rarely) 2 ."Controllers" (maintenance therapy) ---anti-inflammatory medications -inhaled/oral glucocorticosteroids -leukotriene receptor antagonists -anti-allergic agents (cromoglycate, nedocromil) ----bronchodilators -long-acting inhaled 2-agonists (salmeterol,formoterol) -theophylline -ipratropium

Step Therapy of Chronic Asthma During Pregnancy

.

Working Group Recommendations for the Pharmacological

Frequency/Severity of Pulmonary Function* (untreated ) Step Therapy

Category

Mild intermittent

Sx<=2 times per week Nocturnal Sx <=2/month Exacerbations brief (a few hours to a few days) Asymptomatic between episodes Sx > 2 times per week but not daily. Nocturnal Sx > 2/month Exacerbations may affect activity Daily Sx Nocturnal Sx > 1/week. Exacerbations affect activity Continual Sx Limited activity Frequent nocturnal symptoms Frequent acute exacerbations

>=80% Normal function between episodes >=80%

Inhaled beta2-agonists as needed (for all categories)

Mild persistent

Inhaled cromolyn Substitute inhaled beclomethasone if not adequate Inhaled beclomethasone Add oral theophylline Above + oral corticosteroid (burst for active symptoms, alternate day or daily if necessary)

Moderate persistent Severe persistent

60-80%

<60%

Inhaled Steroids
The best option for initial anti-inflammatory treatment (Level I) initial daily dose: 400-1000 g BDP or equivalent (Level III) initial daily dose in children: 200-1000 g BDP or equivalent (Level IV) once best results are achieved, reduce dose to minimum required for control (Level III) Low to moderate doses provide the best risk-benefit profile (Level I) Adults using high doses should consider bone densitometry (Level III monitor IOP in glaucoma patients (Level V) avoid getting aerosolized steroids in the eye (Level V) regular users should rinse after use (Level I) patients requiring consistent high doses should be referred (Level IV)

Leukotriene receptor antagonists

may be considered as an alternative to increased doses of inhaled steroids as add-on therapy to glucocorticosteroids (Level II) There is insufficient data to recommend LTRAs for regular therapy in place of inhaled glucocorticosteroids (Level IV)

Cromoglycate
should not be added to an established regimen of inhaled / systemic steroids (Level I) may be used as a less effective alternative to short-acting 2agonists to prevent exercise-induced symptoms (Level I) may be an alternative to low-dose IHS in children with mild symptoms (Level I) unwilling to take inhaled glucocorticosteroids may be used for short-term allergen exposure (Level I)

Nedocromil
is not recommended for first line therapy of asthma may be considered as a less effective alternative to short-acting 2-agonists to prevent exercise-induced bronchospasm (Level I) may be a modestly effective alternative to low-dose inhaled glucocorticosteroids in children with mild symptoms (Level I)

Theophylline
not recommended as 1st-line therapy (Level I) may be used as an alternative to increased doses of inhaled glucocorticosteroids (Level II) dose must be titrated slowly (Level III) because of the narrow therapeutic range and the potential for severe side effects

Anticholinergic bronchodilators
not recommended as 1st-line therapy except in patients who cannot tolerate 2-agonists (Level III)

long-acting inhaled 2-agonists (salmeterol,formoterol)

These work in the same way as the ordinary relievers such as salbutamol and terbutaline, with the difference that they stick to the cells in the body on which they act, and so work for much longer. The side-effects are the same, namely tremor, increased pulse rate, and palpitations ,They have been introduced much more recently, but no hazards in pregnancy are known.

Other therapies
in chronic severe asthma unresponsive to moderate doses of oral glucocorticosteroids confounding factors should be assessed before increasing therapy patients who need regular oral glucocorticosteroids should be referred to a specialized centre (Level III) and should receive prophylactic osteoporosis treatment (Level I) immunosuppressive agents should be reserved for patients dependent on longterm high-dose glucocorticosteroids (Level III) followed in specialized centres no apparent benefit for most unconventional therapies: acupuncture, chiropractic, homeopathy, naturopathy, osteopathy, herbal remedies (Level I to III, depending on the therapy)

Other treatments for asthma

Antihistamins Antihistamines have very limited effect in asthma (Level of Evidence=B; They can be used to alleviate other symptoms of allergy. Antibiotics Only clear signs of bacterial infection are an indication for antibiotics. Most infections causing exacerbations of asthma are of viral origin. Remember sinusitis, but avoid unnecessary antibiotics. Antitussives Cough is usually a sign of poor control. Increase the intensity of treatment, or give a short course of oral corticosteroids.

Delivery devices
inhaled drug delivery is recommended for 2agonists and glucocorticosteroids (Level I) use the inhalation device that best fits the need of the individual (Level III) health professionals must teach technique when devices are dispensed (Level I) patients' technique must be reassessed and reinforced at each contact (Level II) HFA-propellant devices are recommended over CFC devices (Level IV)-- CFC-free inhalers use hydrofluoroalkanes (HFAs) as the propellant. HFAs are less likely to affect the ozone layer. home wet nebulizers rarely indicated (Level III) in children, conversion from mask to mouthpiece is strongly encouraged (Level II) spacers recommended in certain patients especially in those on high dose IHS (Level I) MDIs with spacers for children <5 (Level II)-Metered Dose Inhalers dry-powder inhalers adequate for age 5+ (Level II) -They are dry powder devices and do not contain a propellant.

Related evidences

Levels of evidence (based on AHCPR 1992).

Ia Evidence obtained from a meta-analysis of RCTs Ib Evidence obtained from at least one RCT IIa Evidence obtained from at least one well-designed, controlled study without randomisation IIb Evidence obtained from at least one other type of well-designed quasiexperimental study III Evidence obtained from well-designed, non-experimental, descriptive studies, such as comparative studies, correlation studies and case-control studies IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

Follow-up
Because asthma is a common disease it should be mainly treated and followed up by a general practitioner. A patient on medication should meet his own doctor regularly. In mild cases one follow-up appointment yearly is sufficient. A two-week measuring of PEF values at home is usually sufficient as follow-up examination,eventually complemented by a simple spirometer examination.

TUBERCULOSIS

EMBOLISME PARU

EMBOLISME PARU

Thank You
Pulmonary Disease Gregory A. Schmidt Medical Disorder During Pregnancy