BRONCHIAL ASTHMA UPDATE

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updated presentation on bronchial asthma , at family medicine departement 15 nov 2011

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BRONCHIAL ASTHMA UPDATE:

BRONCHIAL ASTHMA UPDATE DR. SAEED SALAH ABDULJALIL ASSIST. LECTURER OF FAMILY MEDICINE

Background:

Background Bronchial asthma update

Pulmonary Function Testing :

Pulmonary Function Testing Obstructive lung disease = FEV1/FVC <70% Improvement in FEV1 of at least 12% = reversibility of airway obstruction. Restrictive lung disease :if the FVC is reduced to less than 80% of predicted, in the presence of a normal FEV1/FVC ratio (i.e., no obstruction).

Defining asthma:

Defining asthma Chronic inflammatory disease of airways (AW) ↑ responsiveness of tracheobronchial tree Physiologic manifestation: AW narrowing relieved spontaneously or with BD Clinical manifestations: a triad of paroxysms of cough, dyspnea and wheezing.

GINA DEFINITION:

GINA DEFINITION chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the morning. The episodes are usually associated with widespread but variable airflow obstruction which is often reversible either spontaneously or with treatment ’. The words in this description ‘ many ’, ‘ usually ’, ‘ often ’, imply no precise definition. Furthermore, many of the symptoms overlap with other diseases ( eg chronic obstructive pulmonary disease—COPD). Therefore, asthma largely remains a clinical diagnosis.

Prevalence:

Prevalence Asthma is one of the most common chronic diseases in the world It is estimated that around 300 million people in the world currently have asthma Adults: 2-5% population Children: 15% population 2:1 male/female preponderance in childhood

Mortality:

Mortality Fatal asthma 1-7% asthmatics Risks for death : previous life-threatening asthma severe disease recent hospitalization or emergency room Rx, non-compliant and confusion re Rx, under- treatment with Corticosteroids , discontinued Rx, severe AW hyper reactivity.

Pathophysiology :

Pathophysiology acute asthma: airway obstruction ––> V/Q mismatch ––> hypoxemia ––> ↓ventilation ––> ↑ PaCO2/ ↓ pH AND fatigue ––> ↑ ventilation ↑PaCO2/ ↓ pH

Diagnosis:

Diagnosis Bronchial asthma update

Diagnosis of Asthma:

Diagnosis of Asthma

Key History Points:

Key History Points Symptoms Pattern of Symptoms Precipitating Factors (Triggers) Development of Disease Description of Exacerbation Living Situation Disease Impact Patient’s Perception Family & Medical History

Symptoms:

Symptoms Wheezes(when?) Dyspnea (why) Cough (may be the only presenting symptom) Symptoms of exacerbating RTI

Precipitating factors (Triggers):

Precipitating factors (Triggers) Occupational (animal products, wood dusts, grain dusts, chemicals as Isocyanates ), allergens (pet dander, house dusts, molds) Upper respiratory infection Non-specific factors Cold air and exercise Atmospheric pollution and irritant dusts, vapours and fumes Diet Emotion Drugs Non-steroid anti -inflammatory drugs Beta-blockers

Key Physical Findings Associated With Asthma:

Key Physical Findings Associated With Asthma General (in acute attack) position in bed ,speech ,cyanosis Nose: Rhinitis, Polyps, Mucosal Edema, Increased Secretions Skin: Eczema (flexural) Chest: Thoracic Configuration, Respiratory Rate Use of Accessory Muscles, Quality and Quantity of Breath Sounds, Expiratory Slowing, Wheeze,

Acute exacerbation severity:

Acute exacerbation severity General Position in bed Speech Central cyanosis Pulse Respiratory rate Use of accessory muscles Auscultation PEFR O2 saturation

Diagnostic tests:

Diagnostic tests 1 st to order Spirometer PEFR CBC Chest X ray Tests to consider Sputum eosinophil Serum IgE Allergen Skin prick tests Histamine or methacholine bronchial provocation

Peak flow measurement:

Peak flow measurement Mostly used for clinical follow up of asthma

FEV1 measurement:

FEV1 measurement

Chronic asthma assessment for control and severity:

Chronic asthma assessment for control and severity Severity Daytime Symptoms Night-time Symptoms Pulmonary Function Mild intermittent Mild persistent Moderate persistent Severe persistent

MANAGEMENT:

MANAGEMENT BRONCHIAL ASTHMA UPDATE

Acute attack:

Acute attack SABA ± Ipratropium ± corticosteroids ±adrenaline ±Hospital admission

Acute attack :

Acute attack MILD MODERATE SEVERE OXYGEN THERAPY usually not necessary if available yes SABA salbutamol 1 00 micrograms MDI, 4–10 inhalations (preferably via a large-volume spacer) or 2.5–5 mg by nebuliser , 3- to 4-hourly salbutamol 100 micrograms MDI, 4–10 inhalations (preferably via a large-volume spacer) or 5 mg by nebuliser , 1- to 3-hourly salbutamol 5 mg by nebuliser driven by oxygen (at least 8 L/min). If there is no response to the initial dose, repeat immediately, then every 15–30 minutes or give continuously[ IPRATROPIUM BROMIDE (optional, ipratropium bromide 20 micrograms MDI, 4–8 inhalations (preferably via a large-volume spacer), 4-hourly OR ipratropium bromide 500 micrograms by nebulizer, 4-hourly ipratropium bromide 500 micrograms by nebulizer driven by oxygen (at least 8 L/min) 2- to 4-hourly ADRENALINE imminent cardiorespiratory arrest: adrenaline 0.5 mg (0.5 mL of 1:1000 ampoule) diluted to 10 mL total volume slowly IV, or 0.5 mg (0.5 mL of 1:1000 ampoule) subcutaneously, IM or via endotracheal tube CORICOSTEROIDS prednisolone 25–50 mg orally, daily until attack improves then reduce as appropriate for the patient . prednisolone 50 mg orally, daily until asthma is controlled then reduce as appropriate for the patient Or hydrocortisone 100 mg IV, 6-hourly (or equivalent dose of alternate corticosteroid) then review and convert to oral therapy when appropriate HOSPITAL ADMISSION often necessary yes; consider ICU admission FURTHER MANAGEMENT chest X-ray chest X-ray · check for hypokalaemia · may require assisted ventilation

Acute attack :

Acute attack Most patients do not require and do not benefit from the addition of intravenous aminophylline or of intravenous beta2 agonist

After acute attack:

After acute attack Careful follow-up is mandatory Review trigger factors to identify the possible cause of this attack and discuss avoidance measures Adjust the patient’s maintenance therapy if necessary Adjust the patient’s asthma action plan if necessary

PATIENT EDUCATION:

PATIENT EDUCATION Written information about asthma Self-monitoring and feedback Education about optimal delivery device technique Provision of an individualized written asthma action plan

MAP FOR ASTHMA:

MAP FOR ASTHMA M anagement Plan What do I do every day to control my asthma? A ction Plan What do I do when I have acute symptoms or my peak flowmeter values are dropping? P revention Plan What can I do to control asthma triggers and prevent acute flare-ups?

PowerPoint Presentation:

Drawing by 10-year-old girl with asthma showing how she felt about her illness. She was struggling to take her medicines and had multiple hospital admissions .

Action plan:

Action plan All patients should have an asthma action plan—in written form—that outlines how to: recognise symptoms of asthma deterioration start treatment reach medical attention.

Use of inhalers, spacers and nebulizers:

Use of inhalers, spacers and nebulizers

Control medications:

Control medications BRONCHIAL ASTHMA UPDATE

Clinical Control of Asthma is Defined according to GINA update 2006 As:

Clinical Control of Asthma is Defined according to GINA update 2006 As No (twice or less/week) daytime symptoms No nocturnal symptoms No exacerbations No limitations of daily activities, including exercise No (twice or less/week) need for reliever treatment Normal or near-normal lung function

Summary :

Summary

REFRENCES AND RESOURCES:

REFRENCES AND RESOURCES NAEP guidelines on asthma GINA update British guideline on the management of asthma-may 2008-BTS / SIGN Bestpractice site ( bmj ) Rakel textbook of family medicine 2011

THANK YOU:

THANK YOU DRSAEEDSALAH@GMAIL.COM

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