Asthma and Smoking

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Asthma and Smoking

• John King, M. D.
• March 27, 2007

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Asthma and Smoking

• Asthma is a chronic inflammatory disease
  characterized by bronchial hyper reactivity and
  reversible airflow obstruction if treated.
• Bronchial asthma is a condition of intermittent
  reversible airflow obstruction affecting only the
  airways, not the alveoli.
• Complex molecular and cellular immunologic
  factors mediate asthma.
• Immunologic factors include mast cells,
  eosinophils, thymphocytes, macrohsyes,
  neutrophils.

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Asthma and Smoking

• Many people with asthma have concurrent airway
  inflammation and airway hyperresponsiveness.
• Asthma may occur in some patients after taking
  aspirin or nonsteroidal anti-inflammatory drugs
  (NSAIDs)
• Severe airway obstruction may be fatal.

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Asthma and Smoking

• Asthma obstruction can occur in two ways.
• 1. Inflammation obstructs the lumen or the
  insides of the airways
• 2. Airway hyperresponsiveness results in airway
  obstruction by constricting bronchial smooth
  muscle, causing a narrowing of the airway from
  the outside

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Assessment

• Information to obtain during history gathering
  phase includes.
• 1. Pattern of episode of dypsnea, chest
  tightness, coughing, wheezing and excessive
  amounts of mucous production
• 2. When symptoms occur (e.g., continuously,
  seasonally, in association with specific
  activities, or more often at night) children with
  parents who smoke in the house are more likely to
  have nocturnal asthma.
• 3. Triggers include, carpet, animal inside the
  house, smells and roaches.

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Assessment

• Clinical manifestations during an asthma attack
  include
• 1. Audible wheezing upon expiration
• 2. Increased respiratory rate
• 3. Increased coughing if inflammation is
  present.
• 4. Use of accessory muscles to assist in
  respiratory effort
• 5. Muscle retraction at the sternum,
  suprasternal notch, and between the ribs

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Assessment

• 6. Barrel chest in patient with persistent or
  severe asthma (See Figure 30-3, p. 588)
• 7. Increased anterior-posterior (A-P) diameter
  of the chest

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Assessment

• 8. Longer respiratory cycle, which requires
  greater effort
• 9. Possible cyanotic nail beds and circumoral
  cyanosis
• 10. Possibly unable to complete a sentence of
  more than 5 words per breath
• 11. Pulse oximetry showing oxygen desaturation
• 12. Hypoxemia evidenced by change in level of
  consciousness and tachycardia

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Assessment

• Other assessment data includes
• 1. Arterial blood gases (ABGs)
• 2. Pulmonary function tests
• 3. Chest x-ray examination
• 4. Therapeutic levels of selected medication

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Assessment

• Other allergic symptoms such as allergic
  rhinitis, skin rash, or pruritus may occur with
  atopic or allergic asthma.

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Asthma and Smoking

• Lung and airway changes related to aging is
  thought to be related to a change in the
  sensitivity of beta adrenergic receptors, which
  when stimulated relax smooth muscle and cause
  bronchodilation. As these receptors become less
  sensitive, that can no longer respond as quickly
  or strongly to naturally occurring agonist
  (epinephrine , dopamine) and beta-adrenergic
  medications

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Considerations for Older People

• Asthma occurs as a new disorder in about 3 of
  people over the age of 55.
• Another 3 of people over the age of 60 have
  asthma as a chronic disorder
• Three factors attributed to adult onset asthma
  include
• 1. Longstanding untreated asthma
• 2. Smoking with a known history of childhood
  asthma
• 3. Medication (eg) Beta blockers, premarin and
  aspirin.

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ASTHMA and Smoking Status Asthmaticus

• Status asthmaticus is a severe, potentially life
  threatening acute episode of airway obstruction
  that tends to intensify once it begins and often
  does not respond to common therapy
• 1) Clinical manifestations include extremely
  labored breathing and wheezing, use of accessory
  muscles and distended neck veins.
• 2) The patient may develop a pneumothorax and
  cardiac or respiratory arrest

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ASTHMA and Smoking Status Asthmaticus

• Most smokers/ second hand smoke present to
• the ER with a more severe form of asthma
• Status asthmaticus is treated with intravenous
  fluids, systemic bronchodilators, steroids,
  epinephrine, and oxygen
• The patient may require intubation
• If status asthmaticus is not reversed it may lead
  to cor pulmonale, pneumothorax, and cardiac or
  respiratory arrest

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ASTHMA and Smoking Interventions

• The goal of therapy is to improve airflow,
  relieve symptoms, and prevent episodes by
  including the patient as a key partner in the
  management plan.

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ASTHMA and Smoking Interventions

• Patient education includes
• 1. How to assess symptom severity at least twice
  daily with a peak flow meter
• 2. How to adjust medication (s) to manage
  inflammation and bronchoconstriction to prevent
  or relieve symptoms

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ASTHMAInterventions

• 3. How to use symptom and intervention diary to
  learn his or her triggers of asthma attack
  symptoms, early cues for impending attacks, and
  personal response to medication
• 4. How to use a metered dose inhaler
• 5. How to determine when to consult the health
  care provider

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ASTHMAInterventions

• Drug therapy includes bronchodilators, which
  increase bronchiolar smooth muscle relaxation.
  Bronchodilators have no effect on inflammation.
• 1. Short-acting beta2 agonist are more useful
  when an attack begins or as premedication when
  the client is about to enter an environment or
  begin an activity that is likely to produce an
  asthma attack
• 2. Long-acting beta2 agonist delivered by MDI
  directly to the bronchioles, are useful in
  preventing an asthma attack, but have no value
  during an acute attack.

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ASTHMA and Smoking Interventions

• 3. Cholinergic antagonists allow for increased
  bronchodilation and decreased pulmonary
  secretions
• 4. Anti-inflammatory agents decrease the general
  allergic inflammatory responses in the airways
  they may be administered systemically or as an
  inhalant (eg.) oral steroids, inhaled
  corticosteroids (ICS), theophylline
• 5. Corticosteroids decrease inflammatory and
  immune responses

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ASTHMA and Smoking Interventions

• 6. Nonsteroidal inhaled anti-inflammatory agents
  are helpful in preventing an asthma episode.
• 7. Mast cell stabilizers prevent mast cell
  membranes from opening when an allergen binds to
  IgE they are helpful for preventing symptoms of
  atopic asthma but not useful during an acute
  asthma attack
• 8. Leukotriene antagonists are used to prevent
  persistent asthma

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ASTHMA and Smoking Interventions

• Regular exercise, including aerobic exercise, is
  encouraged the clients exercise routine is
  adjusted to ensure that it does not trigger an
  episode-fro example , adjusting the environment
  in which the activity takes place
• Supplemental oxygen with high flow rates or
  concentration may be used during an asthma
  attack.

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ASTHMA and Smoking

• National Heart, Lung, and Blood Institute/
  American Thoracic
• Society/American Academy of Allergy, Asthma
  Immunology
• (NHLBI/ATS/AAAAI) Task Force.
• Proposed definition for asthma in order to
  standardize
• nomenclature for specific phenotypes of asthma.
• Infection induced Asthma
• 1. New on set asthma
• RSV, parainfluenza, metapneunovirus
• 2. Exacerbation
• RSV, Rhinovirus, Influenza,
  parainfluenza, coronavirus.
• 3. Associated with persistent/chronic
  disease
• Chlamydia pneumoniae, Mycoplasma
  pneumoniae

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ASTHMA and Smoking

• Allergic Asthma
• IgE- Medicated Asthma
• 1. Allergen sensitization by one positive
  skin-prick test.
• 2. IGE sensitivity to specific environmental
  allergens, pollen, weeds, mites
• mold (Aspergillus), and pet dander.
• 3.Childhood onset asthma, allergic
  rhinosinusitis, and symptom
• provocation by environmental triggers.
• 4. Exercise related symptoms
• 5. Sinusitis and nasal polyps

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ASTHMA and Smoking

• Biomarkers
• 1. Peripheral eosinophilia
• 2. Elevated IGE in serum
• 3. Th2-type cytokines (T-helper type 2
  lymphocyte)
• 4. Mast-cell markers

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ASTHMA and Smoking

• Non-allergic Asthma
• 1. Diagnosis already confirmed
• 1. Negative skin prick or RAST (
  radioallergosorbent test) testing seasonal
  and perennial allergens
• 2. Normal to Low IGE
• 3. No history of triggers or
  seasonality
• 4. Adulthood asthma
• 5. No sensitivity to aspirin
• Biomarkers
• 1. Low or normal total IGE levels
• 2. Mucosal IGE synthesis or tissue eosinophilia

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ASTHMA and Smoking

• Definition of Aspirin-Sensitive Asthma
• 1. Documented asthma is in response to asthma
• 2. Probable aspirin sensitivity if sinus
  disease or nasal polyps
• 3. gtage 20
• Biomarkers
• 1. Increase levels of urine leukotrienes ( eg,
  Leukotriene E4)
• 2. CT scanning pansinusitis or nasal polyps
• 3. Aspirin or lysine-aspirin challenge
  

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Asthma and Smoking

• Relationship of Smoking and Cancer of The Lung
  by Alton Ochsner, M.D.
• Annual consumption of cigarettes per capita in
  the U.S. in persons 15 years and older.

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Asthma and SmokingAnnual Consumption Cigarettes
Per capita in U.S. in Persons 15 Years and Older

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Asthma and Smoking
Relationship of Smoking and Lung Cancer by Alton
Ochsner, M. D. The American Surgeon Vol. 21,
1955
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Asthma and Smoking
Relationship of Smoking and Lung Cancer by Alton
Ochsner, M. D. The American Surgeon Vol. 21,
1955
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Asthma and SmokingDeath From Cancer of Lung in
White Males In U.S.
411 Increase
Relationship of Smoking and Lung Cancer by Alton
Ochsner, M. D. The American Surgeon Vol. 21,
1955
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Asthma and Smoking

• Nicotine in Cigarettes up 10 from 1998 to 2004
• Minority Aimed Brands tally Highest Amount
• 1. Marlboro
• 2. Kool Menthol Lights
• Newport menthol filter 100s and Camel nonfilters
  were tied for the highest nicotine at 2.9
  milligrams. And rose to 3.2 milligrams .
• The Washington Post
• By David Brown
• August 31, 2006

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Asthma and Smoking

• Is The Public Health Message On Secondhand
• Smoke Based On Science?
• No, its driven by politics, not good science.
  Stated by Jerome C. Arnett Jr., M.D.
• Public health messages are based on solid
  evidence. Stated by Peter
• Tuteur, M.D.
• Internal Medicine News
• February 15, 2007

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Asthma and SmokingSecondhand Smoking

• Secondhand smoke is called
• Passive
• Involuntary
• Secondhand smoking
• The non-smoker breathes
• Sidestream smoke from the burning tip of the
  cigarette.
• Mainstream smoke that has been inhaled and then
  exhaled by the smoker.
• Secondhand Smoke (SHS)
• Is a major source of indoor air pollution.

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Asthma and SmokingSecondhand Smoking

• Tobacco Smoke Contains over 4000 chemicals in the
  form of particles and gases.
• 85 of the smoke in a room results from
  sidestream smoke .
• Particulate phase includes tar (itself composed
  of many
• chemicals) nicotine, benzene and
  benzo(a)pyrene.
• Gas phase includes carbon monoxide, ammonia.
  dimethylnitrosamine, formaldehyde, hydrogen
  cyanide and acrolein.
• Some of these are marked irritant properties and
  are known or suspected carcinogens (cancer
  causing substances).
• The Environmental Protection Agency (EPA) in the
  USA has classified environmental tobacco smoke as
  a class A (known human) carcinogen along with
  asbestos, arsenic, benzene and radon gas,

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Asthma and SmokingSecondhand Smoking

• Secondhand Smoke Definition
• Environmental tobacco smoke (ETS) is a mixture of
  the smoke given off by the burning end of a
  cigarette, pipe or cigar .
• It is involuntarily inhaled by nonsmokers

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Asthma and SmokingSecondhand Smoking

• Environmental Protection Agency (EPA) classified
  secondhand smoke as
• Known cause of cancer in humans
• Causes disease and premature death in children
  and adults who do not smoke.
• Causes approximately 3400 lung cancer deaths and
  22,700 - 69,600 heart disease deaths in adult
  nonsmokers in the U.S. each year.

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Asthma and SmokingSecondhand Smoking

• Approximately 26 of adults in the United States
  currently smoke cigarettes, and 50 to 67 of
  children under five years of age live in homes
  with at least one adult smoker.

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Asthma and SmokingSecondhand Smoking

• Exposure Environmental Tobacco Smoke (ETS)
• Decreases lung efficiency and impairs lung
  function in children of all ages.
• Increases both the frequency and severity of
  childhood asthma.
• Aggravate sinusitis, cystic fibrosis, and chronic
  respiratory problems such as cough and postnasal
  drip.
• Increases the number of childrens colds and sore
  throats.
• ETS exposure increases the likelihood of
  bronchitis and pneumonia.

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Asthma and SmokingSecondhand Smoking

• Scientific Committee on Tobacco and Health
  (SCOTH)
• Recent reviews by SCOTH found that the
  conclusions of its initial report still stand
  i.e. that there is a causal effect of exposure
  to secondhand smoke on the risks of lung cancer,
  ischaemic heart disease and a strong link to
  adverse effects in children