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asthma
Management
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine
2
CONTENTS
INTRODUCTION
CLASSIFICATION
RISK FACTORS
ASTHMA
Diagnosis
A heterogenous disorder.
Atopic /extrinsic /allergic ( 70%):
o Most common type
o Environmental agent: dust, pollen,
food, animal dander
o Family history - present
o Serum IgE levels - increased
o Skin test with offending agent –wheal
flare
Classification
8
I. Chronic inflammation
I. Inflammation
Chronic inflammatory state
Involves respiratory mucosa from trachea
to terminal bronchioles, predominantly in
the bronchi.
Activation of mast cell , infiltration of
eosinophils & T-helper type 2 (Th2)
lymphocytes
Pathophysiology
12
I. Inflammation
Exact cause of airway inflammation is
unknown.
Thought to be an interplay between
endogenous and environmental factors.
Endogenous factors
Atopy
Genetic predisposition to IgE mediated
type I hypersensitivity
The major risk factor for asthma
Genetics
Pathophysiology
13
I. Inflammation
Environmental factors
Viral infections: RSV, Mycoplasma,
Chlamydia
Air pollution
Allergens :house dust mite
Pathophysiology
14
Host factors:
predispose individuals to, or protect
them from, developing asthma
i. Genetic
o Atopy
o Airway hyperresponsiveness
ii. Gender
iii. Obesity
Risk factors
19
Environmental factors:
influence susceptibility to development of
asthma in predisposed individuals,
precipitate asthma exacerbations, and/or
cause symptoms to persist
o Indoor allergens , Outdoor allergens
o Occupational sensitizers
o Tobacco smoke , Air Pollution
o Respiratory Infections
o Diet
Triggers
20
Asthma Triggers
Allergens
Virus Infections
Drugs
Exercise
Food
Air pollutants
Physical factors
GERD
Stress
Occupational factors
DIAGNOSIS
Clinical manifestations
22
Symptoms
Wheezing, dyspnea and cough.
Variable – both spontaneously and with
therapy.
Symptoms worse at night.
Nonproductive cough
Limitation of activity
Clinical manifestations
23
Signs
↑ respiratory rate, with use of accessory
muscles
Hyper-resonant percussion note
Expiratory rhonchi
No findings when asthma is under control or
b/w attacks
Classification for asthma severity
24
Pulmonary function
tests:
Using Spirometry
estimate degree of
obstruction
↓FEV1, ↓FEV1/FVC,
↓PEF.
Laboratory diagnosis
27
CXR :
hyperinflation,emphysema
Arterial blood-gas analysis
hypoxia & hypocarbia
Skin hypersensitivity test
Sputum & blood eosinophilia
Elevated serum IgE levels
TREATMENT
Management
29
I. Non-Pharmacological
II. Pharmacological
Non-Pharmacological
30
Influenza Vaccination
o should be provided to patients with asthma
when vaccination of the general population is
advised
o routine influenza vaccination of children and
adults with asthma does not appear to protect
them from asthma exacerbations or improve
asthma control
Pharmacological treatment
32
Classification of drugs
Bronchodilators : rapid relief, by relaxation of
airway smooth muscle
β2 Agonists
Anticholinergic Agents
Methylxanthines
Controllers : inhibit the inflammatory process
Glucocorticoids
Leukotrienes pathway inhibitors
Cromones
Anti-IgE therapy
Pharmacological treatment
33
β2 Agonists in asthma
Potent bronchodilators.
Usually given by inhalation route.
Effects:
o Relaxation of airway smooth muscle
o Inhibition of mast cell mediator release
o Reduction in plasma exudation
o Increased mucociliary transport
o Inhibition of sensory nerve activation
No effect on airway inflammation
Pharmacological treatment
34
β2 Agonists in asthma
a) Short-Acting β2 Agonists
E.g salbutamol , terbutaline
Convenient,rapid onset,without significant
systemic side effect
Bronchodil. of choice in acute severe asthma
Used for symptomatic relief
Only treatment required for mild, intermittent
asthma.
Use >2 times a week indicates need of a regular
controller therapy.
Pharmacological treatment
35
β2 Agonists in asthma
b) Long-Acting β2Agonists
E.g salmeterol, formoterol
Duration of action - >12 hrs.
Used in combination with inhaled corticosteroid
therapy.
Improve asthma control and reduce frequency
of exacerbations.
Should not be used as monotherapy (increased
mortality).
Not effective for acute bronchospasm.
Pharmacological treatment
36
Anticholinergic agents
E.g Ipratropium bromide, tiotropium.
Prevent cholinergic nerve induced
bronchoconstriction.
Less effective than β2 agonists.
Response varies with existing vagal tone.
Use in asthma
o Intolerance to inhaled β2 agonist.
o Status asthmaticus –additive effect with β2
agonist
Pharmacological treatment
37
Anticholinergic agents
Ipratropium:
o slow,bitter taste
o precipitate glaucoma
o paradoxical bronchoconstriction
Tiotropium:
o longer acting, approved for treatment of COPD.
o Dryness of mouth
Pharmacological treatment
38
Methylxanthines
Medium potency bronchodilator
E.g Theophylline, theobromine, caffeine
Recently interest has declined in this class of
drugs:
o Side effects
o Need for plasma drug levels
o Pharmacokinetics
o Availability of other effective drugs
Still widely used drugs especially in developing
countries due to their lower cost.
Pharmacological treatment
39
Methylxanthines
Adverse effects
o Anorexia, nausea, vomiting, abdominal
discomfort
o headache, and anxiety
o Seizures or arrhythmias
o Diuresis
Doxyphylline
o long acting,oral
Pharmacological treatment
40
Corticosteroids in asthma
Effective drugs for treatment of asthma.
Development of inhaled corticosteroids is a
major advance in asthma therapy.
Used prophylactically as a controller therapy.
Reduce the need for rescue β2 agonist.
Benefit starts in 1week but continues up to
several months.
If asthma not controlled at low dose of ICS then
addition of long acting β2 agonist is more
effective than doubling steroid dose.
Pharmacological treatment
41
Corticosteroids in asthma
Effects: Broad anti-inflammatory effects:
o Marked inhibition of infiltration of airways by
inflammatory cells.
o Modulation of cytokine and chemokine
production
o Inhibition of eicosanoid synthesis
o Decreased vascular permeability.
o Potentiate effect of β2 agonist.
Pharmacological treatment
42
Corticosteroids in asthma
Inhaled corticosteroids( ICS)
o Use of β2Agonists >2 times a week indicates
need of a ICS
o E.g Beclomethasone , Budesonide , Fluticasone
Pharmacological treatment
43
Corticosteroids in asthma
Inhaled corticosteroids( ICS)
Adverse effects:
o Oropharyngeal candidiasis, dysphonia
o Decreased bone mineral density.
o Skin thinning, purpura
o Growth retardation in children
Pharmacological treatment
44
Corticosteroids in asthma
Systemic steroids in asthma
Indication
1. Acute exacerbation(lung function <30%
predicted)
2. Chronic severe asthma
A 5-10 day course of prednisolone 30-
45mg/d is used.
1% of patients may require regular
maintenance therapy.
Pharmacological treatment
45
Cromones
E.g Cromolyn sodium & nedocromil sodium
On chronic use (four times daily) reduce the
overall level of bronchial reactivity.
have no effect on airway smooth muscle tone
and are ineffective in reversing asthmatic
bronchospasm; they are only of value when
taken prophylactically.
Inhalation route
Pharmacological treatment
48
Cromones
May act by stabilization of Mast cells with
inhibition of mediator release
Uses
o Asthma - Prevention of asthmatic attacks in
mild to moderate asthma
Adverse effects
o Well tolerated drugs
o Minor side effects- throat irritation, cough, and
mouth dryness, rarely, chest tightness, and
wheezing
Pharmacological treatment
49
Anti-IgE therapy:
Omalizumab
recombinant humanized monoclonal antibody
targeted against IgE.
Action:
o IgE bound to omalizumab cannot bind to IgE
receptors on mast cells and basophils, thereby
preventing the allergic reaction at a very early
step in the process.
Pharmacological treatment
50
Anti-IgE therapy:
Use in asthma
o Persons >12 years of age with moderate-to-
severe persistent asthma.
Omalizumab is not an acute bronchodilator and
should not be used as a rescue medication or as
a treatment of status asthmaticus.
Expensive drug
Has to be given under direct medical
supervision due to the risk of anaphylaxis
Status asthmaticus
51
thanks
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