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Asthma. Renmin Hospital, Wuhan University Ding Xuhong ( 丁续红 ). DEFINITION A clinical syndrome of unknown etiology characterized by three distinct components (1) Recurrent episodes of airway obstruction that resolve spontaneously or as a result of treatment (clinical manifestation).

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asthma

Asthma

Renmin Hospital, Wuhan University

Ding Xuhong (丁续红)

slide3
DEFINITION

A clinical syndrome of unknown etiology characterized by three distinct components

(1)Recurrent episodes of airway obstruction that resolve spontaneously or as a result of treatment(clinical manifestation)

slide4

(2)An exaggerated bronchoconstrictor response to stimuli that have little or no effect in nonasthmatic subjects, a phenomenon known as airway hyperresponsiveness (Pathophysiologically)(3) Inflammation of the airways as defined by a variety of criteria (Pathogenesis)

pathology
PATHOLOGY

Constriction of airway smooth muscle

Airway epithelium thickening

Mucus plugging

asthma microscopically
Asthma - Microscopically
  • Patchy necrosis of epithelium
  • Sub-mucosal glandularhyperplasia
  • Hypertrophy of bronchial smoothmuscle
  • Eosinophils,mastcells,lymphocytes (Th2) infiltration
asthma microscopic pathology
Asthma Microscopic Pathology

Obstructed

Inflammed

Bronchi

slide13

PATHOGENESIS

OF ASTHMA

slide14

Asthma Pathogenetic Types

  • Extrinsic (Allergic/Immune)
    • Atopic - IgE
    • Occupational - IgG
    • Allergic Bronchopulmonary Aspergillosis - IgE
  • Intrinsic (Non-immune)
    • Aspirin induced
    • Infection induced
slide16

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
  • Diet
  • Air pollution
    • Outdoor pollutants
    • Indoor pollutants
  • Smoking
    • Passive Smoking
    • Active Smoking

Risk Factors that Lead to Asthma Development

i nducers allergens chemical sensitisers air pollutants virus infections

Airflow Limitation

SYMPTOMS

Cough Wheeze

Dyspnoea

Airway

Hyperresponsiveness

Genetic

InducersAllergens,Chemical sensitisers,Air pollutants, Virus infections

INFLAMMATION

Triggers

Allergens, Exercise,

Cold Air, SO2Particulates

diagnosis of asthma
DIAGNOSIS OF ASTHMA
  • History and patterns of symptoms
  • Physical examination
  • Measurements of lung function
patient history
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 (e.g playing)?
  • Does the patient have breathing problems during a particular season (or change of season)?
slide20
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
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

slide22

Blood Finding

  • Blood eosinophilia, elevated serum level of sIgE
  • Arterial blood gases:

PaO2 between 55 and 70mmHg

PaCO2 between 25 and 35mmHg

slide23

Radiographic finding

In severe asthma, hyperinflation, pneumomediastinum or pneumothorax may be detected

slide24

ECG

Sinus tachycardia (usually), right axis deviation, right bundle branch block, “P pulmonale”, ST-T wave abnormalities (severe asthma)

diagnostic testing
Diagnostic testing

Diagnosis of asthma can be confirmed by demonstrating the presence of reversible and variable airway obstruction using Peak Flow Meter

slide26

Bronchial challenge test: PC20<8mg/mL

  • Reversibility test: FEV1 increase more than 12% after inhalation of salbutamol, the absolute value of increase >200ml
  • Variability of PEF diurnally ≥20%
slide27

Differential diagnosis

  • Chronic bronchitis
  • Heart failure (“cardiac asthma”)
  • Hypersensitivity pneumonia
  • Lung cancer
slide28

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
slide29

Tool Kit for Achieving Management Goals

  • Relievers
  • Preventers
  • Peak flow meter
  • Patient education
what are relievers also known as rescue medication
What Are Relievers? (also known as rescue medication)
  • Bronchodilator (beta2 agonist)
  • Quick relief of symptoms (within 2-3 minutes)
  • Used during acute attacks
  • Action lasts 4-6 hrs
  • Not for regular use
slide31

Relievers

  • Short acting 2 agonists

Salbutamol (万托林)

  • Anti-cholinergics

Ipratropium bromide(爱全乐)

  • Xanthines

Theophylline

  • Adrenaline injections
slide32

What are Preventers?

  • Anti-inflammatory
  • Takes time to act (1-3 hours)
  • Long-term effect (12-24 hours)
  • Only for regular use

(whether well or not well)

slide33

Prevent future attacks

  • Long term control of asthma
  • Prevent airway remodeling
slide34

Preventers

Corticosteroids Anti-leukotrienes

Prednisolone, Betamethasone Montelukast, Zafirlukast

Beclomethasone, Budesonide

Fluticasone Xanthines

Theophylline SR

Long acting 2 agonists Mast cell stabilisers

Bambuterol, Salmeterol Sodium cromoglycate

Formoterol

COMBINATIONS

Salmeterol/Fluticasone

Formoterol/Budesonide

slide35

Patient Education in the Clinic

  • Explain nature of the disease (i.e. inflammation)
  • Explain action of prescribed drugs
  • Stress need for regular, long-term therapy
  • Allay fears and concerns
  • Peak flow reading
  • Treatment diary / booklet
slide36

Status Asthmatic

  • FEV1 < 40%pred with treatment, PaCO2 increases, developing major complication such as pneumothorax
  • Close monitoring
  • Frequent treatments with inhaled β2-agonists, intravenous aminophylline, high-dose intravenous steroid
  • Oxygen supplement
  • Antibiotics – if infection exist
  • If indicated, intubation of the trachea and

mechanical ventilation

slide37

The Pregnant Asthmatic

  • No departure from the ordinary management of asthma
  • No unnecessary medication should be administered
  • Systemic steroid should be used sparingly
  • Tetracycline, atropine, terbutaline(博利康尼?), iodine-containing mucolytics should be avoided
slide38

Key Messages

  • Asthma is a common disorder
  • 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
slide39

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
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