ASTHMA

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ASTHMA
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Definition

• Reversible airflow obstruction
• Airway hyper-reactivity

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Pathology

• Inflammation involving eosinophils and T
  lymphocytes
• Release of various mediators and cytokines
• Initially reversible, spontaneously or with drugs
• Eventually permanent structural change results in
  irreversibility remodelling

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Remodelling

• Extent varies between patients
• Lung function decline faster than in non
  asthmatics
• Early intervention may prevent decline

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Incidence

• 20 of children have asthma
• 6 of adults
• 15 cases are late onset
• Boys . Girls

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Statistics

• 5 million people in uk receive asthma treatment
• NHS treatment costs 850 million/year
• 18 million working days lost/year

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Presentation

• Symptoms
• Cough
• Expiratory wheeze
• Chest tightness
• Dyspnoea
• Nocturnal cough
• Exercise induced wheeze

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Diagnosis

• Twice daily PEF recording for 2 weeks
• 15 variation asthma
• Therapeutic trial of salbutamol
• gt15 improvement in PEF after 15-30 mins asthma
• 2 week trial inhaled or oral steroid
• 15 improvement in PEF asthma

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Differential diagnosis

• Adults
• Gastro oesophageal reflux
• Bronchiectasis
• COPD
• LVF
• PE
• Interstial lung disease
• Tumour

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Differential diagnosis

• Children
• Cystic fibrosis
• Ciliary dyskinesia
• Foreign body inhalation
• Gastro oesophageal reflux
• Bronchiectasis

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Diagnosis - Children

• Cant do PEFR
• Daignosis made on history and response to
  treatment
• 30 children wheeze in first 3 years of life

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Differential diagnosis

• COPD Spirometry fev1/fvc lt 75
• LVF Older, echo lvedp lt50
• PE
• Vocal cord dysfunction
• Psychogenic breathlessness

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Triggers

• Infections particularly viral
• Allergens e.g. house dust mite, pollens, animals.
• Occupations e.g. isocyanate containing paints,
  flour
• Environmental pollutants e.g. cigarette smoke,
  sulphur dioxide

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Triggers

• Drugs e.g. beta blockers
• Exercise
• Cold air
• Hyperventilation
• Foods
• Psychological factors

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Management

• Aims
• Control of symptoms and exacerabtions
• Minimal lifestyle disturbance
• 40 of asthmatics say their symptoms affect their
  lifestyle

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Management

• BTS guidelines
• Stepwise approach

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Step one

• Mild intermittent asthma
• Short acting inhaled beta agoinst as required

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Step two

• Needing beta agonist every day
• Regular preventer therapy
• Add inhaled steroid 200-800micrograms/day
• Start at dose appropriate to severity of disease
• 400 micrograms for most people

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Step 3 add on therapy

• Add inhaled long acting beta agonist LABA
• i.e. salmeterol
• oxis

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Poor response

• Stop LABA
• Increase inhaled steroid to 800mcg/day

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If still symptomatic

• Consider slow release theophyline
• Or
• Leukotriene receptor antagonist

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Step 4

• Increase inhaled steroids
• Adults 2000mcg/day
• Children 800mcg/day
• Add in 4 th drug
• LTRA
• SRT
• Oral beta agonist

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Step 5

• Oral steroids in lowest possible dose
• Maintain high dose inhaled steroids
• Refer to respiratory specialist

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Short acting beta 2 agonists

• Relievers
• Salbutamol and terbutaline
• Use on prn basis
• Useful before exercise

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Short acting beta 2 agonists

• Overuse
• Tachycardia
• Tremor
• hypokalaemia

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Inhaled corticosteroids

• Preventers
• Improves symptoms and lung function
• Might prevent permanent airway damage

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Inhaled corticosteroids

• Beclomethasone, fluticasone and equally
  effective
• Fluticasone twice as potent needs half the dose
• Thrush and dysphonia decreased by rinsing mouth
  out after use abd using a spacer

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Inhaled corticosteroids

• High doses associated with
• Cataract formation
• Adrenal suppression
• Slow growth rate in children no evidence that
  final height is affected

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Adrenal suppression

• Presentation
• Fatigue
• Weigth loss
• Anorexia nausea
• Abdo pain
• Hypoglycaemia
• seizures

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LABA

• Salmeterol and eformeterol
• Patients gt 5 years
• Relieves symptoms and improves lung function
• Adding ALBA to inhaled steroids is more effective
  than doubling the dose of steroid

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LTRA

• Montelukast and zafirlukast
• Block action of leukotrienes
• Montelukast add on therapy age 2 years and
  older
• Zafirlukast monotherapy or add on therapy age
  12 years and older

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LTRA

• Reduce exacerbations
• 5-8 improvement lung function less than inhaled
  steroids or LABA
• 4 week trial continue if symptoms and lung
  function improve

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LTRA

• Side effects
• GIT upset
• Headache
• Rash
• Churg strauss syndrome

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Theophylline

• Phyllocontin continuus
• Has anti inflammatory actions
• Use at step 3
• Side effects
• GIT
• Arrythmias
• Hypokalaemia
• convulsions

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Oral steroids

• Should be under specilaist review
• Monitor
• BP
• Blood sugar
• Osteoporosis prevention

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Delivery systems

• MDI 10 dose reaches lungs
• MDI spacer
• Breath actuated inhaler
• Dry powder inhaler
• Turbohaler
• Accuhaler
• Clickhaler

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Children

• 0-2 yrs mdi spacer mask
• 2-5 yrs mdi spacer
• gt 5 yrs mdi spacer, breath actuated inhaler or
  dry powder inhaler

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Lifestyle measures

• Avoid precipitating factors
• Housedust mite
• Vacuuming
• Impermable matress covers
• Reduced soft furnishings

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Lifestyle measures

• No smoking infamily
• Keep pets out of bedrooms
• Keep weight down

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Acute asthma

• Signs of severity
• Children
• Inability to feed
• Use of accessory muscles
• Sub costal recession
• Nasal flaring

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Acute asthma

• Signs of severity
• Adults
• Pulse gt 110 bpm
• Resp rate gt 25/min
• PEF 33-50 max
• Inability to complete sentenes

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Life threatening

• Cyanosis
• Silent chest
• Bradycardia
• Hypotension
• Poor resp effort
• PEF lt 33 max

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Management

• Oxygen
• Nebulised beta 2 agonist
• Salbutamol 5mg
• Atrovent 500mcg
• Halve doses for children

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Management

• Short course oral steroids
• Adults 40mg/day
• Children gt 5 30mg/day 3 days
• Children 2-5 20mg/day 3 days
• Children lt 2 10mg/day 3 days