Asthma
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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)


Asthma

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)


Asthma

(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

Lung Hyperinflation in Asthma


Asthma

Thickbronchi with Mucous plugs


Mucous plug in asthma

Mucous plug in asthma


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


Asthma

PATHOGENESIS

OF ASTHMA


Asthma

Asthma Pathogenetic Types

  • Extrinsic (Allergic/Immune)

    • Atopic - IgE

    • Occupational - IgG

    • Allergic Bronchopulmonary Aspergillosis - IgE

  • Intrinsic (Non-immune)

    • Aspirin induced

    • Infection induced


Asthma

  • 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)?


Asthma

  • 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


Asthma

Blood Finding

  • Blood eosinophilia, elevated serum level of sIgE

  • Arterial blood gases:

    PaO2 between 55 and 70mmHg

    PaCO2 between 25 and 35mmHg


Asthma

Radiographic finding

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


Asthma

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


Asthma

  • 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%


Asthma

Differential diagnosis

  • Chronic bronchitis

  • Heart failure (“cardiac asthma”)

  • Hypersensitivity pneumonia

  • Lung cancer


Asthma

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


Asthma

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


Asthma

Relievers

  • Short acting 2 agonists

    Salbutamol (万托林)

  • Anti-cholinergics

    Ipratropium bromide(爱全乐)

  • Xanthines

    Theophylline

  • Adrenaline injections


Asthma

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)


Asthma

  • Prevent future attacks

  • Long term control of asthma

  • Prevent airway remodeling


Asthma

Preventers

CorticosteroidsAnti-leukotrienes

Prednisolone, BetamethasoneMontelukast, Zafirlukast

Beclomethasone, Budesonide

FluticasoneXanthines

Theophylline SR

Long acting 2 agonistsMast cell stabilisers

Bambuterol, SalmeterolSodium cromoglycate

Formoterol

COMBINATIONS

Salmeterol/Fluticasone

Formoterol/Budesonide


Asthma

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


Asthma

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


Asthma

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


Asthma

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


Asthma

  • 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


Asthma

Thank you!


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