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Bronchial Asthma:

Bronchial Asthma By Abdelrahman Mahmoud Soliman , MSc,DESA


Definition Chronic reversible inflammatory airway disease characterized by: Airway hyperresponsiveness to a wide range of stimuli. Bronchial inflammation with T lymphocytes, mast cells eosinophils with associated oedema,smooth muscle hypertrophy, matrix deposition, mucus plugging and epithelial damage.


Classification Extrinsic asthma occurs in atopic individuals and commonly start during childhood Intrinsic asthma often starts in middle age from extrinsic causes like NSAIDs , occupational exposure





Clinical Picture:

Clinical Picture Symptoms: Wheeze Cough Expectoration Dyspnea


Signs Cyanosis Decreased chest expansion Normal percussion tone Vesicular breathing with prolonged expiration Expiratory / inspiratory ronchi


Investigation PEFR. Spirometry : Used for patients with low and intermediate probability of asthma demonstrating > 12 % improvement in FEV1 Challenge tests: Methacholine , exercise or mannitol .


continue Blood and sputum esionphilia Tests for atopy CXR




Treatment Non pharmacological House dust mites 1 ++ Food allergen avoidance 1 Avoid smoking 2 + Weight reduction 1 ++


Pharmacological Bronchodilators Short acting ᵦ 2 agonist 1 ++ Muscrinic receptor anatagonist 1 + Theophylline 1 +

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Preventive drugs Inhaled corticoteroids 1 ++ Long acting ᵦ 2 agonist 1 ++ Leukotriene receptor antagonists 1 ++ Theophyllines have some beneficial effect 1 + Sodium cromoglicate and nedocromil sodium Oral steroids

Steroid tablet-sparing Treatment:

Steroid tablet-sparing Treatment Anti Ig E monoclonal antibody Immunosuppresants ( methotrexate , ciclosporin and oral gold) Bronchial thermoplasty . Immunotherapy.

Bronchial Thermoplasty:

Bronchial Thermoplasty In selected adult patients with moderate to severe asthma (aged 18–65 years), who have poorly controlled asthma despite maximal therapy, bronchial thermoplasty treatment has been shown to reduce the frequency of severe asthma attacks, emergency department visits.



Acute severe asthma:

Acute severe asthma

Treatment of acute severe asthma:

T reatment of acute severe asthma Oxygen Inhaled ᵦ2 agonist 1 ++ In severe asthma that is poorly responsive to an initial bolus dose of β2 agonist, consider continuous nebulisation with an appropriate nebuliser . Repeat doses of β2 agonists at 15–30 minute intervals or give continuous nebulisation of salbutamol at 5–10 mg/hour

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Steroid therapy 1 ++ Steroid tablets are as effective as injected steroids, Prednisolone 40–50 mg daily or parenteral hydrocortisone 400 mg daily (100 mg six-hourly) are as effective as higher doses Continue prednisolone 40–50 mg daily for at least five days or until recovery

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Ipratropium Bromide Combining nebulised ipratropium bromide with a nebulised β2 agonist produces significantly greater bronchodilation than β2 agonist alone, leading to faster recovery and shorter duration of admission (0.5 mg 4–6 hourly). 1 +

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Consider giving a single dose of IV magnesium sulphate to patients with acute severe asthma 1 ++ The safety and efficacy of repeated IV doses have not been assessed. Repeated doses could cause hypermagnesaemia with muscle weakness and respiratory fatigue. Nebulised magnesium sulphate is not recommended for treatment in adults with acute asthma. A

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Leukotriene Receptor Antagonists: Current evidence on oral leukotriene receptor antagonists does not support their use in patients with acute asthma. 1 ++ Nebulised furosemide : Although theoretically furosemide may produce bronchodilation , a review of three small trials failed to show any significant benefit of treatment with nebulised furosemide compared to β2 agonists. 1 + Antibiotics: When an infection precipitates an asthma attack it is likely to be viral. The role of bacterial infection has been overestimated. 1 ++

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Heliox The use of heliox , (helium/oxygen mixture in a ratio of 80:20 or 70:30), either as a driving gas for nebulisers , as a breathing gas, or for artificial ventilation in adults with acute asthma is not supported on the basis of present evidence. 1 ++ Intravenous Aminophylline : In an acute asthma attack, IV aminophylline is not likely to result in any additional bronchodilation compared to standard care with inhaled bronchodilators and steroids. 1 ++

Refere to Intensive Care:

Refere to Intensive Care If: deteriorating PEF persisting or worsening hypoxia hypercapnia arterial blood gas analysis showing fall in pH exhaustion, feeble respiration drowsiness, confusion, altered conscious state

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