Asthma

Chronic inflammatory disease of the airway resulting in airway

obstruction.

History
1. Intermittent cough, wheeze, shortness of breath
2. Symptoms are worse at night/early hours of morning and there may
be seasonal variation
3. Symptoms precipitated by:
-Non-specific triggers (cold air, exercise, emotional stress)
-Identifiable allergens (Dust/pollen)
-Occupational factors
4. Family history
5. Frequently associated with post nasal drip, gastro-esophageal reflux

Examination
1. Chest examination normal in stable condition
2. Hyperinflation, wheezing, prolonged expiration, respiratory
distress during acute exacerbation
3. Features of atopy in atopic asthmatics (allergic rhinitis, nasal
polyps, eczema, allergic conjunctivitis)

Diagnosis
PEFR (Peak Expiratory Flow Rate)
-Blow forcefully into a device after a deep inspiratory effort
-3 blows, use the highest value
-An improvement of 60 L/min or 20% or more of the pre-
bronchodilator PEFR, 10-20 mins after inhalation of a beta agonist.
Spirometry
In acute or poorly controlled asthma, Lung Fuction Test will show an
Obstructive picture (FEV1/FVC < 70%)

However administration of SABA (200-400mcg Salbutamol) shows

significant reversibility:
FEV1 increases by 12% and > 200ml

Drug Treatment
Relievers
Short Acting Beta 2 Agonists (eg Salbutamol)
- For immediate relief in acute attack
 - Increasing use= Poor asthma control

Controllers
Inhaled Corticosteroids (Budesonide/beclomethasone)
- Use twice daily even when patient feels well

Assessing response to therapy

-Frequency of asthma symptoms
-Use of Reliever medication
-Night time/early morning awakening
-Limitation of daily activities

Management of Chronic Stable Asthma

a) Controller Drug: Inhaler corticosteroid administered twice daily
on a regular basis (eg Budesonide 200 mcg BD)
b) Reliever Drug: SABA used PRN when symptomatic (eg Salbutamol
200 mcg TDS PRN)
c) If symptoms are still not adequately controlled, consider one of
the following:
-Increase the dose of the inhaled corticosteroid
(Inhaled corticosteroid 400mcg 12 hly)
-Add a long acting B2 Agonist (LABA)/corticosteroid
eg Salmeterol/fluticasone inhalation 50/250 mcg 12 hrly
-Add a leukotriene receptor antagonist
-Add oral Theophylline 200 mg 12hly (max 300mg 12 hrly)
(elderly susceptible to theophylline toxicity)
d)Treat associated conditions eg Obesity, GORD, Rhinitis

NB! Most common cause for poorly controlled asthma: Incorrect

Inhaler technique, so CHECK you patient’s technique
Management of Acute Asthma Exacerbation
a) OXYGEN: Ensure sats >92%)
b) BRONCHODILATOR by Nebulizer: SABA (Salbutamol 5mg) and/or
Short Acting Anti-Cholinergic Agent (Ipratropium Bromide 0.5mg)
c) ANTI-INFLAMMATORY: Hydrocortisone 100mg IVI 6-8 hourly
Change to oral prednisone once clinically improved
(Pednisone 30-40mg OD x 7-14 days)
d) ANTIBIOTICS: If there is strong clinical evidence of bacterial
infection
e) In severe acute exacerbations, poorly responsive to the above:
Magnesium Sulphate 2g in 200ml 0.9% saline infused over 20
mins
f) Intubation and mechanical ventilation is indicated in the
following:
-Deteriorating mental state and/or physical exhaustion (Rising
PaCO2 level or refractory hypoxemia)
- Silent Chest: Extremely severe airway obstruction. Must exclude
pneumothorax
- Cardiac Arrest

Step 1: Mild Intermittent Asthma

< 2 episodes of wheeze and/ or cough per week

< 1 night time cough and/ or wheeze per month
No recent admission to hospital for asthma
PEFR > 80% between attacks

Treatment
Beta 2 agnoist (Salbutamol) inhalation 100-200mcg 1-2 puffs 6-8 hourly
until symptoms are relieved

Step 2: Mild Persistent Asthma

3-4 episodes of wheeze and/or cough per week
2-4 episodes of night time wheeze or cough per month
PEFR > 80% predicted between attacks

Treatment
Beta 2 agonist + Inhaled corticosteroid (Beclomethasone) 200mcg 12
hrly

Review treatment every 3 months until adequate control of symptoms

If control is inadequate: Check adherence and inhaler technique,
exclude on-going exposure to allergens, exclude TB & heart failure.
Once diagnosis is confirmed: Step up therapy is as follows:
Inhaled corticosteroid 400mcg 12 hly

If control still inadequate:

Stop beclomethasone and replace with Inhaled Long acting beta agonist
(LABA)/corticosteroid eg Salmeterol/fluticasone inhalation 50/250 mcg
12 hrly

Step 3: Moderate Persistent Asthma

- 4 episodes of wheeze/cough/tightness per week
- Over 4 night time awakenings per month
- PEFR 60-80% predicted
Treatment
Add slow release Theophylline: 200 mg 12hly (max 300mg 12 hrly)
(elderly susceptible to theophylline toxicity)

Step 4 Severe Persistent Asthma

- Continuous day time wheeze, tightness or cough
- Frequent night time awakenings
- PEFR< 60 %

Stepping down treatment

Attempt reduction in therapy if no acute exacerbations in last 6 months
Gradually reduce the dose or stop regular inhaled corticosteroid
therapy
If symptoms reappear, increase therapy to the level on which the
patient was previously controlled