BRONCHIAL

ASTHMA
- Anindita

What is asthma?
No universally accepted defn.
Diffuse obstructive lung disease, with
- Hyper reactivity of airways to a
variety of stimuli
- High degree of reversibility of
obstructive process

Epidemiology
Onset can be any age
30 % present by 1 year
80 90 % present by 5 years
50 % of asthmatic children virtually
symptom free by 10-20 years
Recurrences in adulthood common
Recent increase in incidence

Stimuli
Viruses, esp RSV

Change of seasons

PATHOPHYSIOLOGY
STIMULUS

LATE REACTION
EARLY REACTION
- Starts within 10
mins

Mast
cells

- IN 2/3 rd patients
- Starts after 3-4 hrs,
peaks at 8-12 hrs

Histamine
LT, PAF

Neutrophils
Eosinophils
infiltrate

And heres what happens

1. Bronchoconstriction

2. Mucosal oedema

3. Mucus
hypersecretion

AIRWAY OBSTRUCTION
( Diffuse, but non uniform)

Subsegmental
atelectasis
Clara cell
damage,
Surfactant
Pulmonary
vasoconstriction

Non uniform
ventilation
V-P mismatch
Alveolar hypo
ventilation

pO2,
pCO2

More in expiration,
Hence:Air trapping
Hyperinflation
Compliance
work of
breathing

Acidosis

Clinical features
Highly variable
Children : Recurrent cough, with or
without wheeze
More at nights
Brought forth by season change

Clinical features (contd)

Acute asthma may begin like cold

Bouts of spasmodic cough at night
Early : non productive
Later : Clear mucoid to yellow sputum
Dyspnoea
Young children : abdo pain
Accessory muscle use

Clinical features (contd)

Profuse sweating
Cyanosis
Hyperresonance from air trapping
Hyperinflation palpable liver, spleen
Feeble breath sounds
Previously audible wheeze
disappears: ominous sign

Clinical features (contd)

Chronic cases

- Barrell shaped chest

- Harrisons sulcus
- Clubbing indicates other underlying
prob, eg CF
Severe cases

- Cyanosis
- Arrythmia
- Pulsus paradoxus

Investigations
Diagnosis mainly clinical
PFTs important in doubtful cases, and
to monitor response to treatment
FEV1/FVC < 80 %
FEV 25-75
PEFR :
- > 20% diurnal difference
- =< 80 % of predicted PEFR
- >= 20% improvement with bronchodilators

Investigations
Absolute eosinophil count
Chest X Ray
- Bilateral symmetric air trapping
- Prominent main pulm artery
- Bronchial cuffing

Allergy test

Sputum/ broncho-alveolar
cytology ?
Curschmann spirals

Charcot Leyden crystals

Creola bodies

Risk factors for asthma

morbidity/mortality
Previous asthma exacerbations
Severe bronchial
hyperresponsiveness
Large diurnal variation in PEF
Poor response to steroids
Food allergy
Environmental exposure
Psychosocial factors

DDs?
Bronchiolitis
Congenital obstructive malformations
lie vascular rings, tracheomalacia
Foreign body aspiration
Hypersensitivity pneumonitis
Cystic fibrosis
MORAL?
All that wheezes is not asthma!

MANAGEMENT

Classification of asthma
severity
severity

Day
Night
FEV1
symptoms symptoms

PEF
variability

Mild
intermitte
nt
Mild
Persistent

2 or less
days /wk

<20%

>2days
/wk

Mod
daily
persistent
Severe
continual
persistent

2 or
less
/month
>2
nights /mn

>80%
predicted

>1
night
/week
frequent

60-80%
predicted

>30%

<60%
preicted

>30%

>80%predi 20-30%
cted

 Treatment of children with asthma

should begin with the most
aggressive therapy necessary to
achieve control, followed by "stepping
down" to the minimal therapy that will
maintain control.

Main groups of drugs

B : Beta agonists ( SABA, LABA)

C : Corticosteroids eg Fluticasone
A : Aminophyllines eg. Theophylline
L : Leukotriene antagonists eg.Montelukast
M: Mast cell stabilisers eg. Ketotifen

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Inhalation Devices

Metered dose inhaler

MDI with Spacer

MDI with Spacer & Facemask

Dry powder inhaler

Nebuliser

 References : O P Ghai, Nelson

Google images for the pictures

Thank you!