Female Bronchial Asthma

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Female Bronchial Asthma

• Dr Muhammad El Hennawy
• Ob/gyn specialist
• Rass el barr central hospital and
• dumyat specialised hospital
• Dumyatt EGYPT
• www.geocities.com/mmhennawy

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Diseases of chest

• COLD----Chronic obstructive lung disease
• reversible (bronchial asthma )
• Irreversible (chronic bronchitis
  chronic obstructive emphysema)
• Reversible and irreversible
  asthmatic bronchitis
• SLD (supurative lung diseases)
• Bilateral---bronchiectasis
• --- infected
  systemic lung
• Unilateral---lung abscess
• --- empyema
• Syndrome of multiple negative pleural
  thickning,
• Pleural effusion ,lung fibrosis

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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.

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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

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Asthma
premenstrual
OCPs
menopause
HRT
pregnancy
delivery
menestrual
Breast feeding
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• 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

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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
  (menestrual 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.

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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)

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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

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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

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Ashtma with pregnancy, delivery,postpartum and
breast feeding
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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.

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causes

• 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

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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.

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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.

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• 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 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

• 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.

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The effect of asthma on pregnancyspecially if
untreated well

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

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

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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 E
  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.

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During delivery

• Only about 1 in 10 women with asthma have
  symptoms during delivery.
• Most asthmatic women are even able to perform the
  Lamaze breathing techniques during delivery
  without difficulty.
• The increase in plasma epinephrine that occurs
  during labor and delivery may contribute to the
  absence of asthma symptoms during this critical
  time period

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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.

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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.

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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

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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

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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 mite-proof 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.

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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

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Self-management of asthma outpatient management
of asthma

• Teach the patient self-management (Level of
  EvidenceA
• 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 EvidenceB
• 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.

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Treatment Protocol
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New Asthma Treatment Algorithm
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Categories of medication

• 1. "Relievers" (for intermittent symptoms)
• -short-acting ß2-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 ß2-agonists
  (salmeterol,formoterol)
• -theophylline
• -ipratropium

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.
.
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Inhaled Steroids

• The best option for initial anti-inflammatory
  treatment (Level I)
• initial daily dose 400-1000 µg BDP or equivalent
  (Level III)
• initial daily dose in children 200-1000 µg BDP
  or equivalent (Level IV)
• once best results are achieved, reduce dose to
  minimum required for control (Level III)
• use a spacer with MDI delivery (Level I)
• 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)

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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)

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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 ß2-agonists 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)

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Nedocromil

• is not recommended for first line therapy of
  asthma
• may be considered as a less effective alternative
  to short-acting ß2-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)

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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

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Anticholinergic bronchodilators

• not recommended as 1st-line therapy except in
  patients who cannot tolerate ß2-agonists (Level
  III)

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long-acting inhaled ß2-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.

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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 glucocorticosteroid
  s 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 long-term 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)

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Other treatments for asthma

• Antihistamins
• Antihistamines have very limited effect in
  asthma (Level of EvidenceB
• 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.

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Delivery devices

• inhaled drug delivery is recommended for
  ß2-agonists 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 lt5 (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.

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Related evidences
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Levels of evidence (based on AHCPR 1992).

• Ia  Evidence obtained from a meta-analysis
  of RCTsIb  Evidence obtained from at least one
  RCTIIa Evidence obtained from at least one
  well-designed, controlled study without  
  randomisationIIb Evidence obtained from at least
  one other type of well-designed  
  quasi-experimental studyIII Evidence obtained
  from well-designed, non-experimental, descriptive
  studies, such as comparative studies, correlation
  studies and case-control studiesIV Evidence
  obtained from expert committee reports or
  opinions and/or clinical experience of respected
  authorities.

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Related evidence 1

• Antileukotienes alone are less effective than
  inhaled steroids for improving lung function and
  quality of life (Level of EvidenceB
• There is not enough evidence to evaluate the
  benefits of influenza vaccination in patients
  with asthma (Level of EvidenceD
• Physical training in patients with asthma
  improves cardiopulmonary fitness but does not
  change lung function (Level of EvidenceB
• There is limited evidence that breathing
  exercises may be of some benefit in asthma (Level
  of EvidenceC
• Methotrexate may have a small steroid sparing
  effect in adults with asthma who are dependent on
  oral corticosteroids (Level of EvidenceB
• Use of cyclosporin may reduce the need of oral
  steroids in asthma but side effects are common
  (Level of EvidenceC
• Gold may reduce the need of steroids in asthma,
  but given the side effects and necessity for
  monitoring the treatment cannot be recommended
  (Level of EvidenceC
• Use of limited asthma education as it has been
  practiced does not appear to improve health
  outcomes (Level of EvidenceC

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Related evidence 2

• There is no overall improvement of asthma
  following treatment of gastro-oesophageal reflux
  (Level of EvidenceC
• There is insufficient evidence to assess the
  benefits of different ways to organise asthma
  care(Level of EvidenceD
• Inhaled corticosteroids are as effective as a
  daily dose of 7.5 to 10 mg or prednisolone,
  probably with fewer adverse effects (Level of
  EvidenceB
• Inhaled beclomethasone has a small dose-response
  effect (Level of EvidenceB
• There is no conclusive evidence of differences in
  relative efficacy between beclomethasone and
  budesonide, although there is some data to
  suggest that BUD via Turbohaler is moreeffective
  than BDP via either Rotahaler of metered dose
  device (Level of EvidenceB
• Doses of fluticasone in the range of 100 µg to
  1000 µg are more effective than placebo in the
  treatment of asthma, low doses being almost as
  effective as high doses in mild-moderate asthma
  (Level of EvidenceA

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Related evidence 3

• Higher potency compounds such as fluticasone may
  be more effective, but there is an excess of
  systemic activity with fluticasone propionate
  compared with other inhaled corticosteroids when
  therapeutically effective doses are compared
  (Level of EvidenceA
• Nedochromil sodium is as effective as
  cromoglycate for exercise-induced asthma (Level
  of EvidenceB
• There is insufficient evidence to compare the
  effectiveness of holding chambers versus
  nebulisers in chronic asthma (Level of
  EvidenceD
• There are no significant differences for any
  important outcomes between standard CFC
  containing pMDI and other devices in the delivery
  of beta-2 agonist for non-acute asthma (Level of
  EvidenceA
• In patients under 60 years of age there is no
  evidence of an effect of inhaled corticosteroids
  at conventional doses given for two or three
  years on BMD or vertebral fractures (Level of
  EvidenceB
• There is some evidence that macrolides may be
  beneficial in some subgroups of asthmatic
  patients, but further studies are needed (Level
  of EvidenceD
• There is no evidence to support the use of
  dehumidification for asthma patients (Level of
  EvidenceD
• lBreathing techniques including slow deep
  breathing, physiotherapy, respiratory muscle
  strengthening, and yoga breathing exercises, are
  not proven to be effective for asthma (Level of
  EvidenceC

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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.

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Expectations (prognosis)

• Asthma is a disease that has no cure.
• With proper self management and medical
  treatment, most people with asthma can lead
  normal lives.

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Dyspnea of pregnancy"

• The important physiologic changes that happen
  during pregnancy include some changes in the
  cardiopulmonary system. Beginning in the first
  trimester and continuing throughout pregnancy,
  mothers experience some "dyspnea of pregnancy"
  whether or not they have asthma elevated
  progesterone levels stimulate increased breathing
  depth and relative hyperventilation.
  Additionally, oxygen consumption is increased
  during pregnancy

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