Bronch ial A sthm a

Sylvia Esevwe & Martin Muriithi

 Defin ition of As thma
 Chronic reversible inflammatory
obstructive lung d’se xcterised by
increased response to stimuli
 Ep id emiology
 Repo rt edl y Unc omm on Co ndit io n –
Afric a
 Before 19 90 p reval ence 0.1 -4%
 Few st ud ies of preva lence
 Higher preval enc e Western Wor ld
 5-1 0%
 Pre va lenc e In creasing Af ri ca And
Western Count ri es
 Epidem. Contd
 Onset at any age bt mo in children
 30% symptomatic by 1 yr of age
 80-90% symptomatic by 4-5yrs of age
 Sex preponderance [M:F]
=1:1 in older children
=1:2 in adults
=2:1 in infants
 Epidemiology Within Africa
 Geogra phica l
Var ia tions
 Ur ban reg io ns --
hi gher pr eval en ce
 Rar e – Ru ra l
 Kenya
 Ru ral pr ev al en ce
5- 13%
 Ur ban pr eval en ce
20%
Hypotheses -- Increase Asthma
 Hygiene Hy pothe sis
 Ex posur e to infec tion ea rli er in lif e—
prot ecti ve a ga inst Ast hma
 Para sit ic Infec tio n
 Western Die t and Obe sit y
 Poll uti on
 Not f ound to caus e As th ma
 May inc rease sympt oms
 Ris k Fa ct or s
 Poverty
 Black race
 Maternal smoking
 Maternal age <20yrs at t.o.b.
 Birth wt <2.5 kg
 Familial/genetic
 Hx of atopy
 Frequent RTI in childhood esp viral
 Bronchial hyperactivity
 Exposure to allergen at infancy
 Et iolog y
 Mult ifa ctori al
 Immunological
 Infection
 Endocrine
 Psychological
 Pharmacologic
 Environmental
 Occupational
 Ty pes
 Allergic/Extrinsic
young child with H/O asthma/allergic
d’se in family
 Idiosyncratic/Intrinsic
no H/O asthma nor allergy, mostly
adults
 Classifica tion
 Mild intermittent
symptoms < x2 a wk, normal FEV1
 Mild persistent
symptoms > x2 a wk, normal FEV1
 Moderate persistent
daily symptoms, FEV1 60-80% of predicted
values
 Severe persistent
continuous symptoms, FEV1 < 60% of
predicted, limitation of physical activity
 Pathop hysiolog y
 Mucosal Inflammation
 Bronchial Hyper-responsiveness
 Patho.cont’d
 Early phase
Inflamm med > airway smooth mm contraction > ^ cap perm, mucous
secretion & ^ in neuronal reflexes
All > bronchoconstriction responsive 2 bronchodilators
1st 6 hrs
 Late phase
Inflamm cells recruitment
=eosinophils >ECP & MBP > a’way desquamation
>nerve ending xposure > hyper responsiveness
Persistence of inflamm effects long after inflamm process
clears
 2 Phases >;
= ^ a’way resist n obstruction
= lung hyper inflation
= V/Q mismatch
= ^ dead space ventilation
= decreased compliance & ^ work of breathing
 Chronic Inflammatory Disorder
 Increased Lymphyocytes, Eosinophils
and Mast cells, Neutrophils
 Mucosal Edema/Inflammation

 Increased Mucous Production

 Assoc Bronchial Hyper-responsiveness

 Triggered by Allergen or Other

Exposures
Pathophysiology Of Asthma
 Allergen Triggers
 Dust mit es
 Molds
 Cockroa ches
 Urba n sett in gs + Africa
 Tree/g ra ss p ollens
 Ber mu da gra ss, Ki ku yu
gra ss, corn pol len , flower
polle n
 Cat & Dog D ander
 Feat hers
 Thr eshi ng
product s
 Bat gu an o
 Other Exposures/Triggers
 Smoke
 To ba cco smo ke rs
in the home
 Co oki ng in
Un ven ti lat ed huts
 Kerosene fu el use
 Occupa tiona l
As thma
 Ov er 200 ag en ts
de scri bed
 Po or ven til at ion in
the wo rkp la ce
 Clin ical P res enta tion
 In ter mit tent
reve rsib le obst ru ct iv e
symp toms
 Ch est tigh tness
 Wh ee zin g
 Co ugh (dry >
pr oductive )
 Po st- tussi ve eme sis
 Wo rse at nig ht
 Asso ciat ion wit h
Tr igge rs
 Phys ic al Ex am F in din gs
 Wh ee zin g
 If seve re  May b e n o wheezi ng
 Pr olonge d Exp ira to ry Ph ase
 Cr ack les / Crepi tat ions
 Pu ls us pa rado xu s
 Ta chy pn oea
 Ta chy car di a
 Hy per inflat io n
 Ot her occas io nal findin gs
 Normal Exam
If not hav in g symp toms
Physical Exam Findings
 St atus As thma tic us
 Severe asthma unresponsive 2 bronchodilators
 Xstics;
=cyanosis
=severe dyspnoea
=systolic hptn
=pulsus paradoxus
=silent chest
=PaO2 <60mmHg
=PaCO2 >50mmHg
=tachycardia
 CXR Findings
 Normal with Mild Increase in Perihilar
markings
 Hyperinflation during an exacerbation
 Secondary to obstructive disease
 Patchy Infiltrates Segmental Atelectasis
 Clears after therapy (unlike infiltrates of PNA)
 Diagnosis
 Sus pic io n on his toric al and cli nic al
gr ounds
 Fami ly hi st ory
 Ot he r At opic Di sease
 Respo nse t o Bronc hodi la tors
 Differential Diagnosis

 Al lTha t Wh eezes Is Not

As thm a

 Not every Asth mati c

wheeze s
 Differential Diagnosis

 URT I
 Ca us ed b y V ir us/ Meas les

 Not responsi ve t o Bronchodi lat ors

 Ingest ed For eign Body

 Cong enit al Hea rt Di seas e/Ca rd ia c
Fa il ur e
 Tracheo esop ha gea l Fist ul a, V asc ula r
Ri ng
 Helmi nt he s Inf ecti on
 Differential Diagnosis

 Bronchi oli ti s
 Most Commonl y RS V

 Not a s clea rl y r evers ib le w /

Bronchod il at ors
 Not a ss oc iated w/ Eo sin ophi li a

 Most co mmonl y dur ing t he f ir st 6 mos

of lif e
 Sea sona l

 Croup=l aryng otr acheobronchi ti s

 Treatment-Avoidance of
Triggers
 Allergen Avoidance-Difficult Rural Settings
in Africa
 Foa m i nst ea d of f eather pil lows
 Pill ow/M att ress Covers
 Reduc tion of books, st uf fed an ima ls ,
rugs i n sl eepi ng a rea s
 Remova l of cats/d ogs
 Pesti cid es t o d ecrea se ex pos ure t o
coc kr oaches
 Prophylactic/Anti-Inflammatory
Treatment

 Inhaled Steroids
 Cor ti cos teroid s interf ere wit h
Inf la mma tor y p roc ess i n mul ti pl e
st eps
 Mi ni ma l, if a ny, si de effec ts
 Singulair/Montelukast
 Leukotr iene a nt agoni st s
 Ma y be u sed in ove r 1 -2 y/o
 Anti-Inflammatory –Others
 Cromolyn (Inhaled)
 Also reduces Ai rw ay Infl amma ti on
 Mas t cel l st abi li zer
 Negl igi ble si de eff ect s
 Ef fec tiv e
 Equ al Theo phyl li ne But wit h less si de
ef fect s
 Comp li anc e di ff icul t— 3-4 t ime s/da y
 Long Acting ß2 Agonists
 Therapeutic/Bronchodilator
Adrenergic Agents
 Ep in eph ri ne
 Bin ds to al l 3 recep to rs ( α , ß1, ß2 )
 Effect s of α  pe ri ph. Va so co nst rict in o
 Effect s of ß1  In cre ase He ar t Rat e
 Effect s of ß2  Bro nch ial Smo oth Mu scl e
Rel ax at io n
 Inh al ed Br onchod il ators
 Salme te rol, Al but ero l
 Bet a Adr ene rg ic Ag oni st s (rel at ivel y sel ect iv e
for ß1 )
 Ro le of ora l Bet a Ago nist s li mi te d
 Terb ut al in e
 Therapeutic-Bronchodilator
 Theoph yllin e
 Met hyl xa nt hin e  Inhi bi ts Act ivi ty of
Ph osp hodi es ter ase (h ydr olyze s cAMP an d
ad en osi ne recep tor an tag onis t)
 Side Ef fect s :N/V, A rry thmi as , Sei zu res,
De at h
 Long te rm ef fect s: Lear ning and Beh avi or
di so rder s
 Nar row Ther ap eu tic Win dow --> mar ke d
in div id ual var iotio n i n The ophy ll ine cle ar an ce
b/w in div id ual s, b/w ag es, & w/ foods and
dr ug i nter act io ns
 Nee d to foll ow leve ls pe rio dica ll y
 Inhaled Medications

 Metered Dose Inhalers (MDI)

 Dry Powdered Device (DPI)
 Nebulizer

 Follow Peak Flow Meter

 Can follow Pea k Fl ow at home
Inhaled Medications-Proper Use
 Without Spacer  With Sp acer
 Ma y Us e Pla st ic

Bott le
 Treatment—Chronic Asthma

 Intermittent – No daily medication

 Mild or Moderate Persistent – Anti-
Inflammatory
 Severe Persistent – Anti-Inflammatory
+++
 Treatment of Asthma
Exacerbation
 Inhaled Bronchodilators

 Steroids – oral

 Oxygen
CASE #1
Case #2
Case #3
 Status Asthmaticus
 Medical Emergency
 Requires Immediate Management
 Often occurs after delay in presentation
for Treatment
 After inadequate treatment (Common in
Resource poor settings
 Status Asthmaticus
 Frequent or Continuous Nebulized
Albuterol
 Atrovent/Ipatropium Bromide used in
severe Asthma for possible synergy
 IV Steroids
 Oxygen
 Terbutaline SQ (or Epi SQ)
 Heliox