Professional Documents
Culture Documents
GROUP MEMBERS
Shathish a/l Thendayuthapani
012012100088
Evelyn Syarmala a/p Paul Raj
012012100022
Rames a/l Poonudurai
012013050217
DEFINITION
PATHOPHYSIOLOGY
TRIGGER FACTORS
CLINICAL FEATURES
DIAGNOSIS
DEFINITION
Asthma is defined as a chronic inflammatory disorder of the
airways in which many cells and cellular elements play a role.
In susceptible individuals this inflammation causes recurrent
episodes of wheezing, breathlessness, chest tightness and
coughing particularly at night or early in the early morning.
These episodes are usually associated with widespread but
variable airflow obstruction that is often reversible either
spontaneously or with treatment.
Asthma is a common and potentially fatal disorder.
PATHOPHYSIOLOGY
TRIGGER FACTORS
A
bronchial infection
gastro-esophageal reflux
CLINICAL FEATURES
The principal symptoms of asthma are :wheezing attacks
chest tightness
breathlessness
cough
Nocturnal symptoms ( usually worst during the night)
Note: Asthma should be suspected in
children with recurrent nocturnal cough & in
people with intermittent dyspnoea or chest
tightness, especially after exercise.
DIAGNOSIS
The diagnosis of asthma is predominantly clinical & based on
a characteristic history.
Supportive evidence is provided by the demonstration of
variable airflow obstruction.
Clinical history compatible with asthma plus either/or :
REFERENCES
Davidsons Principles and Practice of Medicine,
22nd Edition
MURTAGHS GENERAL PRACTICE, 5th Edition,
Mcgraw HILL
www.emedicine.medscape.com
CHRONIC ASTHMA
EVELYN SYARMALA A/P
PAUL RAJ
012012100022
CONTENTS
Assessment of asthma
severity
Non-pharmacological
treatment
Pharmacological treatment
Severity/Grade
Intermittent
Mild persistent
80 %
Moderate
persistent
Symptoms everyday
Night symptoms > weekly
Several known triggers apart
from exercise
60-80%
Severe persistent
Symptoms everyday
Wakes frequently at night
with cough/wheeze
Chest tightness on waking
< 60%
Episodic
Symptoms < weekly
Night symptoms > 2/month
Mild occasional symptoms
with exercise
Lung function
FEV1 or PEFR ( %
predicted)
80 %
Non-pharmacological
treatment
1) Reduce exposure to the allergens
- Dust mites/Carpets/Pollen from flowers/trees
- Animal fur
- Food
- Environment (open burning/haze)
- Chemicals (paint/aerosol/spray)
- Emotional factors (stress/fear)
2) Avoid strenuous physical activity
3) Smoking cessation advice
4) Occupational asthma
5) Proper technique of using inhaler
Pharmacological
treatment
Types and classification of asthma
medication
- Reliever
- Preventer
- Controller
Step up & step down management
Simple Classification
Reliever : bronchodilator
Preventer : anti-inflammatory
Symptom controller : long-acting 2
agonist
Reliever
The three groups of bronchodilators are :
- 2-agonists Salbutamol, Terbutaline,
Salmeterol, Formoterol
- Anticholinergics Ipratropium bromide
(Atrovent),
Tiotropium
- Methylxanthines Theophylline,
Aminophylline
- Omalizumab ( anti-IgE agent)
2-agonists
Examples : Salbutamol, Terbutaline ( short-acting)
Salmeterol, Formoterol ( long- acting)
Stimulate the 2 adrenoreceptors and thus relax
bronchial smooth muscle.
Preferred route of administration : Inhaled
Vehicles of administration : MDI, inhalation, a dry
powder, nebulisation
Inhaled drugs cause bronchodilation in 1-2 minutes
Peak effects by 10-20 minutes
Adverse effects : Headache,palpitation,hypokalemia,
tachycardia
Preventer
Inhaled corticosteroids
- Beclomethasone
- Budesonide
- Fluticasone
Oral prednisolone
Cromolyns
- Sodium cromoglycate
- Nedocromil sodium
Others include :
- Leukotriene receptor antagonist : Montelukast,
Zafirlukast
Corticosteroids
Examples : Inhaled corticosteroids
- Beclomethasone,
- Budesonide
- Fluticasone
Usually in all asthma patients with regular persistent
symptoms even mild symptoms.
Dose range : 400-1600 mcg (adults), aim to keep below 500
mcg for children and 1000 mcg for adults.
Vehicle of administration : MDI, Turbuhaler, Accuhaler
Frequency : once or twice daily
Adverse effects : oropharyngeal candidiasis, dysphonia,cough
NOTE: Rinse mouth with water and spit out after using inhaled
steroids.
Oral prednisolone
Mainly for exacerbations
Given with the usual inhaled
corticosteroid and bronchodilators.
Dose : up to 1 mg/kg/day for 1 to 2
weeks
Adverse effects : minimal if used for
short period of time
Long term use osteoporosis, glucose
intolerance, adrenal suppresion, thinning
of skin, easy bruising
Cromolyns
Examples : - Sodium cromoglycate
- Nedocromil sodium
Vehicle of administration :
Sodium cromoglycate dry capsule for inhalation,
metered dose aerosols, nebuliser solution.
Adverse effects : uncommon, local irritation by dry
powder
Nedocromil is used for frequent episodic asthma in
children over 2 years of age for prevention of
exercise-induced asthma & mild to moderate asthma
in some adults.
Initial dose : 2 inhalations qid
Adverse effects : uncommon
Leukotriene receptor
antagonist
Examples : Montelukast, Zafirlukast
For seasonal asthma & aspirinsensitive asthma, reduce the need
for inhaled steroids or alternative if
cannot tolerate ICS or trouble using
an inhaler.
Montelukast is given as 5 or 10 mg
chewable tablet once daily.
STEP WISE
APPROACH
STEP DOWN
Once asthma control is established,
the dose of inhaled (or oral)
corticosteroid should be titrated to
the lowest dose at which effective
control of asthma is maintained.
Decreasing the dose of ICS by around
2550% every 3 months is a
reasonable strategy for most patients.
REFERENCES
MURTAGHS GENERAL PRACTICE, 5th
Edition, Mcgraw HILL
Davidsons Principles and Practice of
Medicine, 22nd Edition
THANK YOU
ACUTE ASTHMA-ASSESMENT
ACUTE ASTHMA-TREATMENT
ROLES OF TABLET
PREDNISOLONE,TABLET
SALBUTAMOL & LABA
RAMES A/L K.POONUDURAI
012013050217
ACUTE ASTHMA
Worsening of the course of asthma characterized by
increasing symptoms, deterioration in PEF, and increase in
airway inflammation.
Assessment of acute
asthma
High risk patient:
1. Previous severe asthma attack requiring intubation and
ventilation
2. Hospitalization/ Emergency care for asthma in last 12
months
3. Currently not using ICS/ Poor adherence to ICS
4. Long term oral steroid treatment
5. Carelessness with taking medications
6. Night time attacks, especially with severe chest tightness
7. Recent emotional problem
8. Frequent use of SABA, especially for more than 1 month
HISTORY
Assessment of medical history should address:
1. Frequency and severity of recent symptoms,
Rapidity of onset
2. Characteristic of symptoms
3. Distinguish daytime and nocturnal symptoms
frequency
4. History of past/present smoking
5. Activities, acute illness, environmental exposure,
exposure to allergens, psychological stress, use of
NSAIDs that may trigger episodes
6. Family history of asthma/ atopic disease
7. Detailed occupational history
8. Effects of inhalers (if patient is on medication)
1.
2.
3.
4.
5.
6.
7.
PHYSICAL EXAMINATION
General appearance of patient, Difficulty in
talking
Vital signs- Heart rate, respiratory rate, Blood
pressure
Audible wheeze
Nasal flaring, pursed lips, central cyanosis,
Hyperinflation of chest, use of accessory
muscles, tracheal tug
Prolonged expiratory phase, expiratory wheezing
Altered mental status, confusion
Examine for signs of other possible diagnosis (eg
Pneumonia/ pneumothorax)
1.
2.
3.
4.
5.
6.
INVESTIGATIONS
Pulmonary function test- PEFR, Spirometry
Measurement of oxygen saturation by pulse
oximetry- To assess ventilaton status
Arterial blood gas analysis- For patients with
low oxygen saturation on room air, or the
patient who does not respond to initial
treatment with FEV1 remaining less than 30%
Chest X-ray (To rule out upper airway causes of
obstruction, suspicion of pneumonia or
pneumothorax)
Serum potassium concentration
Full blood count, ECG, microbiological
investigation (if required)
MANAGEMENT OF
ACUTE ASTHMA
ATTACK
ROLES OF TABLET
PREDNISOLONE, TABLET
SALBUTAMOL, LABA
Tablet Prednisolone
Dose
Up to 1mg/kg/day for 1-2 weeks (30-60 mg daily)
Action and Use
Short term treatment (5-7 days) is important
early in the treatment of severe acute
exacerbations, with main effects seen after 4-6
hours. Tapering required if treatment given for
more than 2 weeks.
Side effects
Osteoporosis, glucose intolerance, adrenal
suppression and easy bruising with long-term
use
Tablet Salbutamol
A type of selective beta 2 agonist drug
Oral administration rarely required and not
recommended
Inhaled drugs produce measureable
bronchodilation in 1-2 minutes and peak effects
by 10-20 minutes
Brand Name
Formeterol and
budesonide
Symbicort
Formoterol and
mometasone
Dulera
Salmeterol and
fluticasone
Advair
REFERENCES
Murtaghs General Practise 5th Edition
Davidsons Principles of Medicine 22nd
Edition
www.ginasthma.org
www.emedicine.medscape.com
www.asthmapartners.org
South African Medical Journal (SAMJ)