Bronchial

Asthma
Prepared by Clinical Clerk Ena Faye J. Galopo

Batch Soli Gloria Dei 2016

West Visayas State University- College of Medicine

Bronchial Asthma: Definition

Chronic inflammatory condition of the lung airways resulting in
episodic airflow obstruction Nelsons 20 ed
th

A chronic inflammatory condition with reversible airway

obstruction. WHO
Causes symptoms such as wheezing, shortness of breath,
chest tightness and cough that vary over time in their
occurrence, frequency and intensity. These symptoms are
associated with variable expiratory airflow. i.e. DOB air out
of the lungs due to bronchoconstriction, airway wall
thickening and increased mucous. GINA 2015

ETIOLOGY
Genetics
Proinflammatory and
proallergic genes

Environment
Common respiratory viruses:
Cold rhinoviruses
Respiratory syncytial viruses
Human metapneumoviruses
Environmental Tobacco Smoke (ETS)
Common air pollutants
Cold, dry air
Hyperventilation from physical play
or exercise
Strong odors

Etiology/
Pathophysiology
TH2
Cytokines (IL 4.5.13)
B-cells

Inflammatory Cascade

IgE and other Antibodies

Increased production
of growth factors
Mucus gland hypertrophy
Smooth muscle proliferation
Angiogenesis
Fibrosis

Innate and Adaptive Immunity development

(ATOPY)

Viral Infections
Allergens
Environmental Tobacco Smoke
Pollutants/ Toxicants
LOWER AIRWAY INJURY
Persistent inflammation
Airway Hyperresponsiveness
Remodeling
Airway growth & differentiation
ABBERANT REPAIR
ASTHMA

Two Key Defining Features of Asthma

1.A history of respiratory symptoms such as

wheeze, shortness of breath, chest tightness
and cough that vary over time and in intensity
2.Variable expiratory airflow limitation

Types of Asthma

Robbinss 19th ed

1. Atopic Asthma
Most common type
A classic example of Ig-E mediated (type1) Hypersensitivity
reaction
Begins at childhood
Triggered by environmental allergens such as dusts, animal
dander, pollens, cockroach and foods which most frequently
act in synergy with other proinflammatory environmental
cofactors, most notable respiratory viral infections
Family history is common

Types of Asthma

Robbinss 19th ed

2. Non-Atopic Asthma
Do not have evidence of allergen sensitization and skin
test results are usually negative
Respiratory infections (e.g. rhinovirus, parainfluenza virus
and respiratory syncytial virus) are common triggers

Inhaled air pollutants may also contribute to the chronic

airway inflammation and hyperactivity in some cases

Types of Asthma

Robbinss 19th ed

3. Drug-induced Asthma
4. Occupational Asthma

Types of Childhood Asthma

NELSONS 20th edition

1. Recurrent Wheezing
primarily triggered by common respiratory viral
infections, usually resolves during the preschool/lower
school years

2. Chronic Asthma
associated with allergy that persists into later childhood
and often adulthood

SIGNS & SYMPTOMS

Intermittent dry cough
Expiratory wheezing
Shortness of breath

Chest congestion and tightness

Intermittent, nonfocal chest pain
Self imposed limitation of physical activity

Generalized fatigue
Difficulty in keeping up with peers

PHYSICAL EXAMINATION

Rapid or increased RR
Hyperinflation of the chest
Hypoxia (O2 sat <90%)
Use of accessory muscles for
respiration
Best noted with the feeling of
the neck muscles

Expiratory wheezing
Prolonged exhalation phase
Decreased breath sounds in
other lung fields

Rhonchi and crackles

SEVERE Exacerbation:
Inspiratory and expiratory
wheezing
Increased prolongation of air
entry
Suprasternal and intercostal
retraction
Nasal flaring
Use of accessory muscles

Respiratory Symptoms
Are they typical of asthma?
Further history & tests for alternative diagnoses
Alternative diagnosis confirmed?
Detailed history and examination
for Asthma
History/ examination supports
Asthma diagnosis?
Further history and tests for alternative diagnoses
Alternative diagnosis confirmed?

Clinical urgency & other dx unlikely

Perform Spirometry/ PEF with reversibility test

Results support asthma diagnosis?
Empiric treatment
of SABA and ICS
Diagnostic testing within
1-3 mos

Treat for ASTHMA

Repeat on another occasion or

arrange other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis,
Or refer for further investigations

Treat for alternative diagnosis

CRITERIA for DIAGNOSIS

1. A history of variable respiratory

symptoms
People with asthma generally have more than one of these
symptoms

The symptoms occur variably over time and vary in intensity

The symptoms often occur or are worse at night or on
waking

Symptoms are often triggered by exercise, laughter,

allergens or cold air
Symptoms often occur with or worsen with viral infection.

2. Evidence of variable expiratory airflow

limitation
At least once during the diagnostic process when FEV1 is low,
document that the FEV1/FVC ratio is reduced.
Normal for Adults: 0.75-0.80
Normal for Children: >90

2. Evidence of variable expiratory airflow

limitation
Variation in lung function is greater than in healthy
people.
Bronchodilatory reversibility- FEV increases by more
than 12% and 200ml after inhalation.

In children >12% of the predicted value

Average Diurnal PEF variability is >10% (in children >13%)
FEV1 increases by more than 12% and 200 ml from baseline after
4 weeks of anti-inflammatory treatment (outside respiratory
infections)

2. Evidence of variable expiratory airflow

limitation
The greater the variation, or the more times excess variation is seen,
the more confident you can be of the diagnosis
Testing may need to be repeated during symptoms, in the early
morning, or after withholding bronchodilator medications
Bronchodilator reversibility may be absent during severe
exacerbations or viral infections. If bronchodilator reversibility is not
present when it is first tested, the next step depends on the clinical
urgency and availability of other tests.

Typical spirometric tracings

Normal

FEV1

Asthma
(after BD)
Asthma
(before BD)

Flow

Normal
Asthma
(after BD)
Asthma
(before BD)

Volume
1

Note: Each FEV1 represents the highest of three

reproducible measurements

ASSESSING A PATIENT WITH ASTHMA

1. ASTHMA CONTROL assess both symptom control and risk factors
Assess symptoms over the last 4 weeks
Identify any other risk factors for poor outcomes
Measure lung function before starting treatment, 3-6 months later, and then periodically, e.g.
yearly
2. Treatment Issues

Record the patients treatment, and ask about their side effects
Watch the patient using their inhaler, to check their technique
Have an open empathic discussion about adherence
Check if the patient has a written asthma action plan
Ask the patient about their attitudes and goals for their asthma

3. Are there any comorbidities?

These include rhinitis, rhinosinusitis, gastroesophageal reflux (GERD), obesity, Obstructive

Sleep apnea, depression and anxiety
Comorbidities should be identified as they may contribute to repiratory symptoms and poor
quality of life. Their treatment may complicate asthma management.

ASTHMA CONTROL
Extent to which the effects of asthma can be seen in the
patient , or have been reduced or removed by
treatment.

2 Domains:
Symptom control
Risk factors for future outcomes

Assessment of symptom control and Future Risk

A. Level of Asthma Control
In the past 4 weeks, has the patient had:

Daytime symptoms >2x a week?

Y/N

Any night waking due to asthma?

Y/N

Reliever needed >2x a week?

Y/N

Any activity limitation due to asthma?

Y/N

Well
Partly
Uncontrolled
Controlled Controlled
None of
these

1-2 of
these

3-4 of these

Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, particularly for patients experiencing
exacerbations.
Measure FEV1 at start of treatment, after 3-6 months of controller treatment to record personal
best lung function, then periodically for ongoing risk assessment
Potentially modifiable independent risk factors for exacerbations include:
Uncontrolled asthma symptoms
ICS not prescribed; poor ICS adherence; incorrect inhaler technique
High SABA use (with increased mortality if >1x200-dose canister/month)
Low FEV1 especially if <60% predicted
Major psychological or socioeconomic problems
Exposures: smoking, allergen exposure if sensitized
Comorbidities: Obesity, rhinosinusitis, confirmed food allergy
Sputum or blood eosinophilia
Pregnancy
Other major independent risk factors for flare-ups (exacerbations) include:
Ever being intubated or in intensive care for asthma
Having 1 or more severe exacerbations in the last 12 months

Having 1 or more of
these risk factors
increases the risk of
exacerbations even
if symptoms are
well controlled.

Risk factors for poor asthma outcomes

RF for developing fixed airway limitation include:
Lack of ICS treatment
Exposure to tobacco smoke, noxious chemicals or occupational exposures
Low FEV1
Chronic mucus hypersecretion
Sputum or blood eosinophilia
RF factors for medication side-effects include:
Systemic: frequent OCS; long-term, high dose and/ potent ICS; also taking
P450 inhibitors
Local: high-dose or potent ICS; poor inhaler technique

Asthma Severity Assessment

Retrospective Assessment from the level of treatment
required to control the symptoms and exacerbations.
MILD ASTHMA
- can be controlled with Step 1 and 2 treatment

SEVERE ASTHMA
- requires 4 or 5 of treatment to maintain symptom control

How to investigate
Uncontrolled Asthma

Watch patient using their inhaler. Discuss adherence and barriers to use
Compare inhaler technique with device-specific checklist, and correct errors; recheck frequently. Have an empathic discussion
about barriers to adherence

Confirm the Diagnosis of Asthma

If lung function is normal during symptoms, consider having ICS dose and repeating lung function after 2-3 weeks

Remove potential risk factors. Assess and manage comorbidities

Check for risk factors or inducers such as smoking, beta-blockers, NSAIDs, allergen exposure. Check for comorbidities such as
rhinitis, obesity, GERD, depression/anxiety.

Consider Treatment Step-up

Consider step-up to next treatment level . Use shared decision-making, and balance potential benefits and risks.

Refer to a specialist or severe asthma clinic

If asthma is still uncontrolled after 3-6 months on Step 4 treatment, refer for expert advice. Refer earlier if symptoms are
severe if with doubts about the diagnosis

MANAGEMENT
LONG TERM GOALS:

Symptom control

Risk reduction

Treating to control symptoms &

minimize risk
Medications. Every patient with asthma should
have a reliever medication, and most adults and
adolescents with asthma should have a controller
medication.
Treating modifiable risk factors

Nonpharmacological Therapies and strategies

CONTROL-BASED ASTHMA MANAGEMENT

Assess

Symptoms
Exacerbations
Side-effects
Patient
Satisfaction
Lung function

Review
Response

Diagnosis
Symptom control and Risk Factors
(including lung fxn)
Inhaler technique and adherence
Patient Preference

Adjust
Treatment

Asthma medications
Non-pharma strategies
Treat modifiable risk
factors

Initial Controller Treatment

Early treatment with low dose ICS leads to better lung
function than if symptoms have been present for more
than 2-4 years
Patients not taking ICS who experience severe
exacerbations have lower long-term lung function than
those who have started ICS
In occupational asthma, early removal from exposure
and early treatment increase the probability of recovery

Initial Controller Treatment

Regular low-dose ICS is recommended for patients
with any of the following:
Asthma symptoms more than twice a month
Waking due to asthma more than once a month

Any asthma symptoms plus any risk factor(s) for

exacerbations (e.g. needing OCS for asthma within the
last 12 months; Low FEV1; ever in intensive care unit for
asthma)

Initial Controller Treatment

Higher step (e.g. medium/ high dose ICS or
ICS/LABA) is considered if:
the patient has troublesome asthma symptoms on most
days

waking up from asthma once or more a week

especially if there are any risk factors for exacerbations

Before starting controller treatment

Record evidence for the diagnosis of asthma, if

possible

Document symptom control and risk factors

Assess lung function, when possible
Train the patient to use the inhaler correctly and
check their technique

Schedule a follow-up visit

After starting controller treatment

Review response after 2-3 months, or
according to clinical urgency
Consider step down when asthma has been
well-controlled for 3 months

Assess

Symptoms
Exacerbations
Side-effects
Patient Satisfaction
Lung function

Review

Diagnosis
Symptom control and Risk Factors (including lung fxn)
Inhaler technique and adherence
Patient Preference

Adjust
Treatment

Response

Asthma medications
Non-pharma strategies
Treat modifiable risk factors

PREFFERED CONTROLLER CHOICE

STEP 1

STEP 3
Low dose
ICS/ LABA

STEP 2
Low dose ICS

STEP 4
Med/ high
ICS/LABA

STEP 5
Refer for addon treatment
e.g. anti-Ige

Add Tiotropium
High dose ICS +
LTRA (or Theoph)

Add Tiotropium
Add low dose
OCS

OTHER CONTROLLER OPTIONS

Consider low
dose ICS

Leukotriene Receptor Antagonists

(LTRA)
Low dose theophylline

Med/high dose ICS

Low dose ICS +
LTRA (or + Theoph)

RELIEVERS

As-needed Short-Acting Beta2-agonist (SABA)

As needed SABA or Low dose ICS/ Formoterol

Diagnosis
Symptom control & risk factors
(including
lung function)
Diagnosis
InhalerSymptom
technique &control
adherence
& risk factors
Patient(including
preference lung function)

Inhaler technique & adherence

Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

GINA 2015, Box 3-2

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

STEP 1: As needed inhaled Short-acing

Beta2-agonist
Preferred option: as needed inhaled SABA

All children who experience wheezing episodes should be provided

with inhaled SABA for relief of symptoms, although it is not effective in
all children
Other options
Oral bronchodilator therapy is not recommended due to its slower
onset of action and higher rate of side effects compared with inhaled
SABA. For children with intermittent viral-induced wheeze and no
interval symptoms in whom inhaled SABA medication is not sufficient,
intermittent ICS may be considered, but because of the risk of side
effects, this should only be considered if the physician is confident that
the treatment will be used appropriately.

STEP 2: Initial Controller Treatment plus

as-needed SABA
Preferred option: Regular daily low dose ICS plus as-needed SABA
Regular daily, low dose is recommended as the preferred initial treatment to control
asthma in children 5 years and younger. This initial treatment should be given for at least 3
months to establish its effectiveness in achieving good asthma control

Other Options:
In young children with persistent asthma, regular treatment with a leukotriene receptor
antagonist (LTRA) modestly reduces symptoms and need for oral corticosteroids
compared with placebo. In young children with recurrent viral induced wheezing, regular
LTRA improves some asthma outcomes compared with placebo but does not reduce the
frequency of hospitalizations, courses of prednisone or number of symptom free days. For
pre-school children with frequent viral-induced wheezing and with interval asthma
symptoms, as needed or episodic ICS may be considered but a trial of regular ICS should
be undertaken first .

STEP 3: Additional controller treatment,

plus as needed SABA
If 3 months of initial therapy with a low dose ICS fails to control symptoms, or if exacerbations
persist, check the following before any step up treatment is considered:
Confirm that the symptoms are due to asthma rather than a concomitant or alternative condition
Check and correct inhaler technique.
Confirm good adherence with the prescribed dose.
Inquire about risk factors such as allergen or tobacco smoke exposure

Preferred option: Moderate dose ICS (double the low dose)

Doubling the initial low dose of ICS may be the best option. Assess response after 3 months.
Other options
Addition of a LTRA to low dose ICS may be considered, based on data from older children.

Choosing an inhaler device for children

5 years
Age

Preferred device

Alternate device

03 years

Pressurized metered dose

inhaler plus dedicated
spacer with face mask

Nebulizer with face mask

45 years

Pressurized metered dose

inhaler plus dedicated
spacer with mouthpiece

Pressurized metered dose

inhaler plus dedicated
spacer with face mask, or
nebulizer with mouthpiece
or face mask

Severe Life-threatening Asthma

The patient is:
In severe respiratory distress
With central cyanosis

Reduced oxygen saturation <90%

Poor air entry (Silent Chest)
Unable to drink or speak

Exhausted or confused

Primary care management of

acute asthma or wheezing in
pre-schoolers

PRIMARY CARE

ASSESS the CHILD

C h i l d p r e s e n t s w i t h a c u t e o r sub-acute asthma e x a c e r b a t i o n
or acute wheezing episode
Consider other diagnoses
Risk factors for hospitalization
Severity of exacerbation?

MILD or MODERATE

SEVERE OR LIFE THREATENING

Breathless, agitated
Pulse rate 200 bpm (0-3 yrs) or 180 bpm (4-5 yrs)
Oxygen saturation 92%

any of:
Unable to speak or drink
Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic retractions
Oxygen saturation <92%
Silent chest on auscultation
Pulse rate > 200 bpm (0-3 yrs)
or >180 bpm (4-5 yrs)

START TREATMENT
Salbutamol 100 mcg two puffs by pMDI + spacer
or 2.5mg by nebulizer
Repeat every 20 min for the first hour if needed
Controlled oxygen (if needed and available):
target saturation 94-98%

URGENT

MONITOR CLOSELY for 1-2 hours

Transfer to high level care if any of:
Lack of response to salbutamol over 1-2 hrs
Any signs of severe exacerbation
Increasing respiratory rate
Decreasing oxygen saturation

Worsening,
or lack of
improvement

TRANSFER TO HIGH LEVEL CARE

(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer (or
2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max.
30 mg for 25 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.

MONITOR CLOSELY for 1-2 hours

TRANSFER TO HIGH LEVEL CARE

(e.g. ICU)

Transfer to high level care if any of:

Lack of response to salbutamol over 1-2 hrs
Any signs of severe exacerbation
Increasing respiratory rate
Decreasing oxygen saturation

Worsening,
or lack of
improvement

IMPROVING

CONTINUE TREATMENT IF NEEDED

Worsening,
or failure to
respond to
10 puffs
salbutamol
over 3-4 hrs

Monitor closely as above

If symptoms recur within 3-4 hrs
Give extra salbutamol 2-3 puffs per hour
Give prednisolone 2mg/kg (max. 20mg for
<2 yrs; max. 30mg for 2-5 yrs) orally

While waiting give:

Salbutamol 100 mcg 6 puffs by pMDI+spacer (or
2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 25 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.

IMPROVING

DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan

FOLLOW UP VISIT

Reliever: Reduce to as-needed

Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique
and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
Schedule next follow up visit

GINA 2015, Box 6-8 (3/3)

Initial assessment of acute asthma

exacerbations in children 5 years
Symptoms

Mild

Severe*

No

Agitated, confused or drowsy

>95%

<92%

Sentences

Words

<100 beats/min

>200 beats/min (03 years)

>180 beats/min (45 years)

Central cyanosis

Absent

Likely to be present

Wheeze intensity

Variable

Chest may be quiet

Altered consciousness

Oximetry on presentation
(SaO2)**
Speech
Pulse rate

*Any of these features indicates a severe exacerbation

**Oximetry before treatment with oxygen or bronchodilator

Take into account the childs normal developmental capability

Indications for immediate transfer to

hospital for children 5 years
Transfer immediately to hospital if ANY of the following are present:
Features of severe exacerbation at initial or subsequent assessment
Child is unable to speak or drink
Cyanosis
Subcostal retraction
Oxygen saturation <92% when breathing room air
Silent chest on auscultation
Lack of response to initial bronchodilator treatment
Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated
3 times) over 1-2 hours
Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the child shows other
clinical signs of improvement
Unable to be managed at home
Social environment that impairs delivery of acute treatment
Parent/carer unable to manage child at home

Initial management of asthma

exacerbations in children 5 years
Therapy

Dose and administration

Supplemental
oxygen

24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 9498%

Inhaled SABA

26 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first

hour, then reassess severity. If symptoms persist or recur, give an additional 2-3
puffs per hour. Admit to hospital if >10 puffs required in 3-4 hours.

Systemic
corticosteroids

Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for

children <2 years; 30 mg for 2-5 years)

Additional options in the first hour of treatment

Ipratropium bromide

For moderate/severe exacerbations, give 2 puffs of ipratropium bromide

80mcg (or 250mcg by nebulizer) every 20 minutes for one hour only

Magnesium sulfate

Consider nebulized isotonic MgSO4 (150mg) 3 doses in first hour for children
2 years with severe exacerbation