Dr.

kais AlAbaidy

Asthma is defined as a chronic inflammatory disorder of the airways. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or early in the morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.

Asthma is a condition of the airways where there is difficulty in breathing due to

Inflammation

Swelling

Excess mucus

Or a combination of all three

Disease of chronic inflammatory disorder of the airways Characterized by

Airway inflammation Airflow obstruction Airway hyperresponsiveness

Children have smaller airway passages, therefore higher resistant Elastic tissue recoil is lower than adults and fewer collateral airways-prone to obstruction.

Indoor Air Pollutants Outdoor Air Pollutants Other Types of Triggers

Second Hand Smoke Pits (furred / feathered) Biological Volatile Organic

Compounds

Ozone (O3) Particulate Matter

Nitrogen Dioxide (NO2) Sulfur Dioxide (SO2)

Vigorous Exercise Exposure to Cold

Sudden Changes in Temperature

Excitement OTC Medications

Non-Steroidal Anti-Inflammatories

With exposure to a trigger, a cascade of cellular responses result in:

Increased mucus production Mucosal swelling Bronchial muscle contraction

Early Acute Result is:

Hyperesponsiveness Obstruction Recurrence of symptoms in 4-12 hours

Airway Remodeling

Late Acute Result is:

Chronic Result is:

Mild Intermittent Asthma Mild Persistent Asthma Moderate Persistent Asthma Severe Persistent Asthma

CLASSIFY SEVERITY
Clinical Features Before Treatment Nighttime Day Symptoms Symptoms Continuous Frequent Limited physical activity
Daily Use b2-agonist daily Attacks affect activity

STEP 4 Severe Persistent

STEP 3 Moderate Persistent STEP 2 Mild Persistent

STEP 1 Intermittent

>1 time a week

>1 time a week but <1 time a day

>2 times a month

< 1 time a week Asymptomatic and normal PEF between attacks

<2 times a month

The presence of one of the features of severity is sufficient to place a patient in that category. Global Initiative for Asthma (GINA) WHO/NHLBI, 2002

Infants Children Teenagers Pregnant Women

The rational for asthma pharmacotherapy centers on 2 main areas: reversal or prevention of bronchial smooth muscle constriction and reversal or prevention of airway inflammation.

Achieve and maintain control of symptoms

Prevent asthma episodes or attacks

Minimal use of 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

Relievers Sympathomimetic bronchodilators (most) Injected methylxanthine, e.g., aminophylline Controllers Theophylline (i.e., oral methylxanthine) Anticholinergics bronchodilators Corticosteroids Leukotriene receptor inhibitors/antagonists

Bronchodilators (Sympathomimetics) Bronchodilators (Anticholinergics) Inhaled Corticosteroids Biologic Response Modifiers (Monoclonal Antibodies) Leukotriene Receptor Antagonists Mast Cell Stabilizers Methylxanthene Derivatives

albuterol (Ventolin):Short-acting beta2 agonist epinephrine (Adrenalin) isoproterenol (Isuprel) terbutaline (Bricanyl) Salmeterol(Long-acting beta2 agonist (Serevent Diskus)

NOT for acute symptoms NOT for deteriorating asthma NOT a substitute for inhaled or oral corticosteroids

Activate beta-2 receptors on bronchiolar smooth muscle

Marked relaxation of the smooth muscles of the bronchi Most efficacious and reliable for reversing bronchospasm

Ipratropium ( atrovent ) : It acts by blocking muscarinic receptors in the lung, inhibiting bronchoconstriction and mucus secretion. Used for the Treatment of COPD( chronic Obstructive pulmonary disease)

Beclamethasone Triamcinalone

An important consideration for corticosteroid use in asthma is the fact that they do not directly cause bronchial smooth muscle relaxation but rather reduce the frequency and severity of asthma attacks. Thus, patients still need to have access to a quick acting 2 bronchodilator to treat the acute bronchospastic phase of asthma.

Decrease inflammation Increase the number and sensitivity of Beta-adrenergic receptors Inhibit the migration and function of inflammatory cells (esp. eosinophils).

Side effects of oral corticosteroid uses may include endocrine suppression, increased risk of infections, osteoporosis, cataract formation, fluid and electrolyte imbalances and impaired growth and development in children. their potential long-term side effects limit their oral use.

Omalizumab ( Xolair ):It is a preventative measure only and not for acute episodes . for subcutaneous use is an inject able, prescription medicine for patients 12 years of age and older. It is for patients with moderate to severe persistent allergic asthma caused by year-round allergens in the air. A skin or blood test is done to see if you have allergic asthma. XOLAIR is for patients who are not controlled by asthma medicines such as inhaled steroids. A severe allergic reaction (anaphylaxis )has happened in some patients after they received XOLAIR

Montelukast( Singular ) : Used also to prevent exercise-induced bronchoconstriction . Zafirlukast ( Accolate ): It is a competitive and selective Leukotriene receptor antagonist indicated for the prophylaxis and treatment of chronic asthma children 6 to 14 years of age have found a similar efficacy and side effects profile to that in adults . Adverse reactions, such as diarrhea, pharyngitis, nausea and sinusitis were slightly more frequent in the pediatric group than adult .

Cromolyn Nedocromil Inhaled Inhibit the release of histamine Effective in some patients only Some local irritation, cough, rhinitis, sneezing, throat irritation

Chromones

Disodium cromoglycate (cromolyn sodium, Intal, Nasalcrom) Nedocromil (Tilade)

It blocks the release of Histamine from mast cells , Histamine is a strong bronchoconstrictor ,it is not considered as antihistaminic drug as it cant prevent the effects of Histamine once the Histamine released from the mast cells .

Theophylline

An initial maintenance therapy in patients who are more likely to adhere to an oral than inhaled regimens.

An initial maintenance therapy when administration of inhaled corticosteroids is difficult in some cases as in young children.

It is not a preferred alternative in maintenance therapy due to its side effects and the need of therapeutic drug monitoring TDM. CNS stimulation: headache , insomnia ,irritability and even seizures. CVS: tachycardia ,palpitations and It is not a prefered alternative in maintenance therapy due to its side effects and the need of theraputic drug monitoring TDM) but it has a low cost hypotension. GIT: abdominal pain ,nausea and vomiting.

Rapid IV injection may cause palpitations,

-Theophylline clearance may be reduced by allopurinol, some

antiarrhythmics, cimetidine, disulfiram, fluvoxamine, interferon alfa, macrolide antibacterials and quinolones, oral contraceptives, tiabendazole, and viloxazine, necessitating dosage reduction.

-Theophylline clearance may be increased by phenytoin and some other antiepileptics, ritonavir, rifampicin, and sulfinpyrazone, necessitating an increase in dose or dosing frequency. -Theophylline administration with ephedrine or other sympathiomimetics may cause cardiac arrythmias.

-Theophylline may increase the excretion of lithium ,so lithium dose should be adjusted.

Intravenous magnesium sulphate A single intravenous dose of magnesium sulphate over 20 min has been shown to be safe and effective in acute severe asthma. Magnesium is a smooth muscle relaxant, producing bronchodilator.

Burning at the site of infusion, decreased systolic blood pressure, increased serum magnesium levels 1 hour after infusion, skin flushing, feeling warm If Mg>3 mg/dl: CNS depression If Mg>5 mg/dl: Facial flushing If Mg>12 mg/dl: Muscle weakness Respiratory depression Cardiac conduction abnormalities (complete heart block) Hypotension, diarrhea.

Is it truly effective (MgSo4) ? Are there better outcome measurements? Is there a dose/response relationship? Is it cost effective if the drug does NOT reduce hospital admissions?

Oral Slow onset of action Large dosage used Greater side effects

Inhaled route Rapid onset of action

Less amount of drug used

Better tolerated Treatment of choice in acute symptoms

Not useful in acute symptoms

Discharge home medication can be mostly done : If Sustained improvement in symptoms: Normal physical findings. O2 sat >92% in room air for 4 hrs. Discharge medications: Inhaled B agonist Q 3-4 hrs. Oral steroids for 3-7 days.

Asthma Education Cognitive Behavioral Therapy

Relaxation Exercises

Chinese Herbal Therapy