CASE DISCUSSION

BRONCHIAL
ASTHMA

BRONCHIAL ASTHMA
Chronic Inflammatory disorder of
bronchi characterized by Episodic,
reversible bronchospasm resulting
from an exaggerated
bronchoconstrictor response to various
stimuli (allergy)

ASTHMA--PATHOGENETIC
TYPES
Extrinsic (Allergic/Immune)
Atopic - IgE
Occupational - IgG
A. Bronchopulomonary Aspergillosis - IgE

Intrinsic (Non immune)

Aspirin induced
Infections induced

AETIOLOGY

FACTORS WHICH MAY PREDISPOSE TO

ASTHMA:

Childhood infections e.g respiratory

syncytial virus
Allergen exposure
Indoor pollution
Dietary deficiency of anti-oxidants
Exposure to pets in early life

FACTORS WHICH MAY PROTECT

AGAINST ASTHMA
Living on farms
Large families
Childhood infections including
parasites
Predominance of lactobacilli in gut
flora

PRECIPITATING AGENTS

PATHOPHYSIOLOGY

PRESENTATION OF ASTHMA
ACUTE SEVERE ASTHMA
Acute Severe Asthma
Life threatening Asthma
Near Fatal Asthma

PRESENTATION OF ASTHMA
CHRONIC STABLE ASTHMA:
Mild Intermittent asthma
Mild Persistent
Moderate Persistent
Severe persistent

CLASSIFICATION OF SEVERITY
OF CHRONIC ASTHMA
MILD
INTERMITTENT
MILD PERSISTENT
MODERATE
PERSISTENT
SEVERE
PERSISTENT

CLINICAL FEATURES
SYMPTOMS
Feeling of chest tightness
Episodes of dyspnea
Non-productive cough which
aggravates dyspnea
Wheeze

SIGNS:
Tachycardia
Tachypnea
Breath sounds vesicular with prolonged
expiration
Audible wheeze
Widespread polyphonic wheeze
Hyper-inflated chest
Hyper-resonant percussion note

FEATURES OF ACUTE SEVERE

ASTHMA

PEF 33-50% predicted(<200L/min)

Respiratory rate >25/min
Heart rate >110/min
Inability to complete sentences in one
breath

LIFE-THREATENING FEATURES
PEF <33%
predicted(<100L/min)
SaO2 <92% OR PaO2
<8kPa(60mmHg)
Normal PaCO2
Silent chest
Cyanosis
Feeble Respiratory effort
Bradycardia or Arrhythmias
Hypotension
Exhaustion
Confusion
Coma

NEAR FATAL ASTHMA

Raised PaCO2 and/or requiring
mechanical ventilation with raised
inflation pressures

DIFFERENTIAL DIAGNOSIS

COPD
Acute bronchitis
Pneumothorax
Large airway obstruction
Left ventricular failure
Pulmonary embolism
SVC obstruction
Extrinsic allergic alveolitis

INVESTIGATIONS
CHRONIC ASTHMA:
BLOOD CP
ABSOLUTE EOSINOPHIL COUNT
SERUM IgE LEVEL
CHEST X-Ray
SPIROMETRY
FEV1
FEV1/FVC, RV
REVERSIBILTY TEST
EXERCISE TEST
PEF MONITORING
HISTAMINE or METHACHOLINE
CHALLENGE TEST
SKIN PRICK TEST
CULTURE FOR FUNGAL HYPHAE

INVESTIGATIONS
ACUTE ASTHMA:
ABGs
PEF
SPUTUM CULTURE
CHEST X-RAY
BLOOD CP
CRP

DIAGNOSIS OF ASTHMA
Compatible Clinical history plus either/or:
FEV1 > 15%(and 200ml)increase following
administration of a
bronchodilator/corticosteroids
>20% diurnal variation on > 3 days in a week
for 2 weeks on PEF diary
FEV1 > 15% decrease after 6 minutes of

MANAGEMENT

GOALS OF ASTHMA
MANAGEMENT
Achieve and maintain control of symptoms
Prevent asthma exacerbation
Maintain pulmonary function as close to
normal as possible
Avoid adverse effects from asthma
medication
Prevent development of irreversible airflow
limitation
Prevent asthma mortality

MANAGEMENT OF CHRONIC
ASTHMA.
STEP WISE APPROACH
STEP1:
Occasional use of

INHALED

SHORT ACTING -2
ADRENOCEPTOR

STEP2
Low dose INHALED
CORTICOSTEROIDS (or other antiinflammatory agents)

STEP--3
Low to moderate dose INHALED
CORTICOSTEROIDS plus LONG ACTING
INHALED -2 ADRENOCEPTER AGONIST
or LEUKOTRIENE RECEPTOR
ANTAGONIST

STEP--4
High dose INHALED
CORTICOSTEROIDS and REGULAR
BRONCHODILATORS

STEP--5
Addition of regular ORAL
CORTICOSTEROID therapy

STEP DOWN TREATMENT

Occasional temporary step ups will be
needed to control exacerbation
Consider step down if good symptom
control for 3 or more months
Withdraw anti-inflammatory
treatment if patient well for atleast
6 months

PRECAUTIONARY MEASURES
FOR ASTHMATICS

Dust control measures at homes

Avoid wall to wall carpeting
Adequate air ventilation
Dont keep pets at homes
Avoid smoking
Dont keep flowers and plants in rooms

Contd
Cockroach control measures
Avoid physical exercise in case of
exercise induced asthma
Avoid perfumes and sprays
Avoid eatables which aggravate
asthma

THE REALITY
Asthma is not yet curable *
Under-diagnosed & Under-managed
Therapy is still evolving

HOPE
Better understanding of Pathology
New line of Promising Drugs.
Proper management normal life.