Bronchial Asthma

Presented by
 Asthma
Asthma is characterized by hyperresponsiveness of tracheo
bronchial smooth muscle to a variety of stimuli resulting
in narrowing of air tubes often accompanied by
 Increased secretion,
 Mucosal edema
 Mucus plugging
 Cough
 Bronchospasm
 Dysapnea
 Wheezing.
 Shortness of breath
 Chest tightness
Pathogenesis of asthma

Exposure to stimuli/ allergens/ specific condition

Production of antibody (IgE)

Release of vasoconstrictor and inflammatory substances by mast cells

Inflammation and vasoconstriction

Migration of
Phagocytic cells
Enhanced mucus secretion
Phagocytosis

Release of basic lytic Air way narrowing & obstruction

enzymes
Asthma Pathological Change

4
 Types Of Asthma

Extrinsic (allergic) asthma :

More prevalent in the younger age group
It is caused by the immune system’s response to inhaled allergens.
It responds quite well to the use of inhaled steroids as these suppress the
immune system

Intrinsic (non-allergic) asthma :

It is caused by anything except an allergy.
It may be caused by an infection, stress, laughter, exercise, cold air, food
preservatives or a host of other factors.

Occupational asthma :
Occurs due to a trigger in the place of work. Common triggers include pollutants
in the air, such as smoke, chemicals, fumes, dust, or other particles.
 Types Of Asthma

Sports asthma/Exercise-induced asthma :

Shortness of breath and coughing occurring after an exhausting exercise is termed
exercise-induced asthma.
Occur about 5-20 minutes after beginning an exercise
Precautions include using a bronchodilator inhaler just prior to the sports activity.

Drug induced asthma :

Special type of intrinsic asthma.
acute asthma attacks on first and subsequent exposure to aspirin and NSAID
 Investigation / Diagnosis
1. Patient’s history and the symptoms being displayed

2. Patient’s family history should not be neglected, as it has a strong chance of

influencing the patient

3. A physical examination of the upper respiratory tract, Using a nasal mirror, look
inside the nose for signs of allergic disease such as increased nasal secretions,
swelling. These signs may suggest that allergies are responsible for triggering
suspected asthma.

4. Use a stethoscope to listen to the sounds the lungs make while breathing.
Wheezing sounds indicate one of the main signs of asthma: obstructed airways.

5. Finally, examine the skin for signs of allergic conditions such as eczema or hives,
which are often associated with asthma.
 Investigation / Diagnosis
1. Patient’s history and the symptoms being displayed

2. Patient’s family history should not be neglected, as it has a strong chance of

influencing the patient

3. A physical examination of the upper respiratory tract, Using a nasal mirror, look
inside the nose for signs of allergic disease such as increased nasal secretions,
swelling. These signs may suggest that allergies are responsible for triggering
suspected asthma.

4. Use a stethoscope to listen to the sounds the lungs make while breathing.
Wheezing sounds indicate one of the main signs of asthma: obstructed airways.

5. Finally, examine the skin for signs of allergic conditions such as eczema or hives,
which are often associated with asthma.
 Investigation / Diagnosis
Conti…
6. Spirometry – Breathing Test
Spirometry measures three values that are important in
diagnosing asthma:
a) Vital capacity (VC), which is the maximum amount of air that
one can inhale and exhale
b) Peak expiratory flow rate (PEFR), also known as the peak
flow rate, which is the maximum flow rate one can generate
during a forced exhalation
c) Forced expiratory volume (FEV1), which is the maximum
amount of air you one exhale in one second
If certain key measurements are below normal for a
person your age, it may be a sign that the airways are
obstructed
 Investigation / Diagnosis
Conti….
7 Challenge test - During this test, a deliberate attempt is made to trigger airway
obstruction and asthma symptoms by inhaling an airway-constricting chemical or
taking several breaths of cold air.

8 Chest and sinus X-rays.

9 The doctor may also test a person’s pulmonary function after administering him
some asthma medication. This helps confirm that the blockage in the air passages
that shows up on pulmonary function tests goes away with treatment.
 Predicted Values Measured % Predicted
Values
FVC 6.00 liters 4.00 liters 67 %
FEV1 5.00 liters 2.00 liters 40 %
FEV1/FVC 83 % 50% 60%

Person is asthmatic

 Making a diagnosis of asthma :

• FEV1≥15% (and 200 ml) increase following administration of a
bronchodilator/trial of corticosteroids
• >20% diurnal variation in PEF on ≥ 3days in a week for 2 weeks
• FEV1 ≥ 15% decrease after 6 mins of exercise
 The goals of asthma management
treatment

 Achieve and maintain control of symptoms

 Prevent asthma exacerbations

 Maintain pulmonary function as close to normal as possible

 Avoid adverse effects from asthma medications

 Prevent development of irreversible airflow limitation

 Prevent asthma mortality

 Management of asthma
1. Avoidance of aggravating factors
2. Use pharmacologic agents
a) Quick relief medications :
 Bronchodilators that inhibit smooth-muscle contraction
 β-Adrenergic agonists
 Methylxanthines
 anticholinergics
b) Long term control medications :
 agents that prevents or reverse inflammation
 Glucocorticoids
 leukotriene inhibitors
 receptor antagonists
 mast cell-stabilising agents
 Medication used in Asthma

 Quick Relief Medications or Bronchodilators :

Bronchodilators relaxing the airway muscle, so opens the airways, as a result,
breathing improves.
Bronchodilators also clear mucus from the lungs.

1) β -Adrenergic agonists :

a. Short-acting inhaled form :

These are also called "quick acting or rescue" medications
These inhalers are the best for treating sudden and severe or new asthma
symptoms.
They work within 20 minutes and last four to six hours.
Available as inhalers as well as pills
 Medication used in Asthma

b. Long-acting forms of beta 2-agonists :

Used to control asthma.
These drugs take longer to show effect, but their benefits last longer, even up to
12 hours.
They are available as inhalers as well as pills.
When the long-acting beta-adrenergic agonists are used together with inhaled
corticosteroids, better results are obtained.

 Side effects of beta 2-agonists include :

Nervous or shaky feeling
Overexcitement or hyperactivity
Increased heart rate
2) Anticholinergic drugs :
 These are used to control asthma.

 It is available in both a metered-dose inhaler and a nebuliser solution.

 Anticholinergic drugs take about 60 minutes before they start working.

 They work best when used with a short-acting beta 2-agonist inhaler.

 Doctors use anticholinergic drugs mainly in the emergency situations in

combination with a beta-2 agonist. When used alone, anticholinergics are only
marginally effective.

 Side effects are minor, with dry throat being the most common.
3) Theophylline drugs :
 Available as an oral (pill and liquid) or intravenous drug.
 Theophylline and various salts; adjust dose to maintain blood level between 5
and 15 g/ mL; IV (as aminophylline).
 Theophylline clearance varies widely and is reduced with age,
hepatic dysfunction, cardiac decompensation, cor pulmonale.
 Many drugs also alter theophylline clearance (decrease half-life: cigarettes,
phenobarbital, phenytoin; increase half-life: erythromycin, allopurinol,
cimetidine, propranolol).
Side effects include:
Nausea, Diarrohea, Imsomnia, Headache, Irregular heartbeat, Muscle cramps,
nervous feeling.
These symptoms may be a sign of having taken too much medication hence important
to check your blood levels.
 Long term control medications :

1)Glucocorticoids
 Systemic or oral administration are most beneficial.
 Not useful in acute asthma.
 For exacerbations of asthma in the outpatient setting, prednisone 40–60 mg PO
daily
 Agents available include beclamethasone, budesonide, flunisolide, fluticasone
proprionate, and triamcinolone acetonide.
 In addition to local symptoms, systemic effects may occur (e.g., adrenal
suppression, cataracts, bone loss).
 Combination of an inhaled steroid (fluticasone) and β2 agonist (salmeterol) is
gaining widespread use
2) Cromolyn sodium and nedocromil sodium :
 Useful in chronic therapy for prevention, not useful during acute attacks Because
the drugs may block acute bronchoconstriction when administered 15–20 min
before exposure to antigens, chemicals, or exercise, they may be of use in
selected patients who have predictable attacks of extrinsic asthma (exercise
induced).
 Administered as metered-dose inhaler or nebulized powder, 2 puffs daily.

3) Leukotriene modifiers :
 They are anti-inflammatory drugs, which prevent the synthesis of leukotrienes
(chemicals made by the body that cause bronchoconstriction).
 These drugs, orally taken, are used to prevent asthma attacks rather than treat
them, but can be used during an attack as well.
Inhaled Asthma Medication
Four Classes Of Asthma Drugs:
1. β2 Agonists
2. Anticholinergics
3. Cromoglycate
4. Glucocorticoids

Aerosol are of two types

1) Use drug in solution : metered dose inhaler,
nebulizer
2) Use drug dry as powder : spinhaler, rotahaler
 A stepwise approach to the management of
asthma
 Step up Therapy :

 Step 1 : Occasional use of inhaled short-acting β2 adrenoreceptor

agonist bronchodilators
Inhaled short acting β2-agonist used in patients with mild intermittent
asthma (symptoms less than once a week for 3 months and fewer than two
nocturnal episodes per month)

 Step 2 : Introduction of regular preventer therapy

Regular anti-inflammatory therapy (preferably ICS) should be started in addition
to inhaled β2-agonist in patient who :
has experienced an exacerbation of asthma in last 2 years uses inhaled
β2-agonist 3 times a week or more reports symptoms 3 times a week or
more
is awaken by asthma one night per week.
 A stepwise approach to the management of
asthma

Starting dose is 400μg Beclometasone dipropionate (BDP) per day in adult

BDP and budesonide (BUD) are approximately equivalent
Fluticasone and mometasone provide equal clinical activity to BDP/BUD at half the
dosage.
 Step 3 : Add – on therapy
If patient remains poorly controlled despite regular use of ICS A further increase in the
dose of ICS may benefit Add on therapy should be considered beyond an ICS dose of
800μg/day BDP in adults Long acting β2-agonist (LABA), salmeterol and formoterol
(duration of action of at least 12 hours) LABA improve asthma control and reduce the
frequency and severity of exacerbation copare to increased dose of ICS alone.
 A stepwise approach to the management of
asthma

Combination inhalers of ICS and LABAs have been developed. Adv- more convenient,
increase compliance.Leukotriene receptor antagogonists (e.g. monteleukast 10mg daily)
are a relatively new class of agents, delivered orally.Theophyllines may be useful in
some patients but their unpredictable metabolism, drug interactions, side effects have
limited their use.

 Step 4 : Continuous or frequent use of oral steroids

At this stage Prednisolone therapy (usually administered as a single daily dose in
morning) is given to control the symptoms. Patients receiving corticosteroid tablets for
more than 3 months or receiving more than 3-4 courses per year will be at risk of
systemic side-effects.
 A stepwise approach to the management of
asthma

 Step down therapy :

Once asthma control is established, the dose of inhaled (or oral) corticosteroids
should be reduced to lower dose at which effective control of asthma is maintained.
 Exacerbations of Asthma :
Exacerbations are characterized by-
# increased symptoms
# deterioration in Peak expiratory flow
# increase in airway inflammation
Exacerbations may be precipitated by-
# infections ( most commonly viral)
# moulds ( Alternaria and Cladosporium)
# pollens (particularly following thunderstorm)

 Management of mild-moderate exacerbations :

Short courses of ‘rescue’ oral corticosteroids (prednisolone 30-
60mg daily) used to regain control of symptoms. withdraw
treatment, after using for more than 3 weeks.
 Acute severe asthma :
Initial assessment

Acute severe asthma

 PEF 33-50% predicted (<200 l/min)

 Respiratory rate ≥ 25/min
 Heart rate ≥110/min
 Inability to complete sentence in 1 breath

Life-theatening features

 PEF 33-50% predicted (<200 l/min)

 SpO2<92% or PaO2<8kPa (60mmHg), Normal PaCO2
 Silent chest
 Cyanosis
 Feeble respiratory effort
 Bradycardia or arrythmias
 Confusion
 Coma

Near-fatal asthma

 Raised PaCO2 &/or requiring mechanical ventilation

 Management of acute severe
asthma

1. Oxygen :
High concentration of oxygen (humidified if possible) to maintain the oxygen saturation
above 92% in adults.
Failure to achieve appropriate oxygenation is an indication for assisted ventilation.

2. High doses of inhaled bronchodilators :

Short acting β2-agonist administered via a nebulizer driven by oxygen
Multiple doses of salbutamol via a metered dose inhaler through a spacer
Combination of salbutamol and ipratropium bromide

3. Systemic corticosteroids :
Administered orally Prednisolone 30-60mg
IV hydrocortisone 200mg
4. Intravenous fluids :
Potassium supplements may be necessary because repeated doses of salbutamol can
lower serum potassium

Subsequent management :
IV magnesium may provide additional bronchodilator in patients whose presenting PEF
is <30% predicted
Use of IV leukotriene receptor antagonists

Monitoring of treatment :
PEF should be recorded every 15-30min and then every 4-6 hrs.
Pulse oximetryb should ensure that SaO2 remains >92%
 Antiasthmatic Combinations
1) BRONKOPLUS : salbutamol 2mg, anhydrous theophylline
100mg tab.,also per 5ml syrup.

2) BRONKOTUS: Bromohexine 4mg, salbutamol 2mg tab,.also

syrup- bromohexine 4mg,salbutamol2mgper 5ml

3) TERPHYLIN: Terbutaline 2.5mg, etophylline100mg tab.

4) THEO ASTHLIN : Salbutamol 2mg, theophylline anhydrous

100mg tab.

5) THEO BRIC: Terbutaline 5mg, theophylline 100mgtab.

 Case Study

Que. Mr. PG is a 42 –years-old recently diagnised asthamatic. He is

non-smoker. He has been measured his PEF regularly since diagnosis
and has a morning-to-night diurnal variation of between 380 and 500
L/min(his best value) His current medication is:
* beclometasone pressurized MDI 200μg twice a day
* salbutamol pressurized MDI 200 μg when required
He comes to you for his next review. During your discussion, Mr PG
tells you that he has noticed that he is wheezing more at night than
previously and wakes up two or three times a night. He is also
affected by cold air whilst walking to work, necessitating the use of
his salbutamol most mornings
 Case Study

Ans.
 Case study

Que. Mrs JS is attending the hospital respiratory outpatient clinic, 3 weeks after her
fourth hospital admission for exacerbation of her asthma in a year. She is 44 and
has been diagnosed with asthma since the age of 4
Her current medication is:
* salbutamol pressurized MDI 2 puffs when required
* seretide-250 pressurized MDI 2 puffs twice a day
* prednisolone tablets 8 mg once daily
* theophylline M/R 500mg twice daily
* methotrexate tablets 10mg once a week.

She has required oral steroids in addition to her seretide for 3 years; she started at
15mg daily and is now reduced to 8mg. She has been talking the methotrexate for
3 months but has not managed to reduced her oral steroid dose. She has also tried
oral ciclosporin in the past year to try and help reduced this, with no effect.
 Case study

Ans.
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• K.D. Tripathi, Essentials of medical pharmacology, jaypee
brothers publishers,6th edition,pp.216-227.
• Roger walker,Cate whittlesea, Clinical Pharmacy and
Therapeutics,Fourth edition, pp.367-384.
•