Bronchial Asthma and COPD

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Bronchial Asthmaand Chronic Obstructive
Pulmonary Disease (COPD)
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Asthma

• Chronic Inflammatory (allergic) disorder of
  airways, characterized by
• Episodic, Reversible bronchospasm
• (i.e narrowing of airways) and airway
• responsiveness
• resulting from an exaggerated broncho-constrictor
  response to various stimuli (triggers)

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Epidemiology

• Common disease at all ages
• Prevalence Adults 2-5
• Children Up to 10
• Total global burden App 300 millions
• Expected by 2025 100 m. additional
• Loss of DALYs About 15 m./year
• (around 1 of all DALYs lost)
• Accounts for 1 in every 250 deaths
• Considerable economic costs

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Asthma Pathophysiology
INFLAMMATION
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Lumen
Mucosa
Muscle
Muscle hypertrophy
Mucosal inflammation, edema
Airway narrowing
Mucus plugging
Mucus gland hypertrophy
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Causes of Asthma

• Hereditary presence of atopy (allergy)
• Environmental triggers/ causes
• Infections
• House dust mites, other insect
  products
• Pollens of grasses and trees
• Dusts and smokes
• Chemical vapours

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Misc. Risk Factors for Asthma

• Presence of allergic rhinitis or other allergies
• Gastroesophageal reflux ?
• Obesity ?
• Exercise
• Cold climate
• Drugs and chemicals
• Other occupational exposures
• Psychological factors
• Allergic bronchopulmonary aspergillosis
• Tobacco smoking

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Indoor Air Pollution

• Biomass Fuel Combustion
• Environmental Tobacco Smoke (ETS)
• Others
• Environmental
• Biological (bacterial, fungal)
• Construction related
• Consumer products
• House dust (etc.)

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Factors influencing atopy

• Allergen exposure
• Dose of allergens
• Infections and infestations may promote or
  suppress an IgE response
• Nutrition Variable
• Obesity Higher incidence
• Cod liver oil widely recommended
• Vit. B12, Vit. C, nicotinic acid
• Selenium - ? protective

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Aggravating Factors (GER)

• Old age
• Autonomic dysfunction lowering of lower
  esophageal sphincter tone
• Gastroesophageal regurgitation, hiatus hernia
• Medication Beta blockers, other
  anti-hypertensive drugs

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Asthma - triggers

• Home environment
• Aero allergens
• House dust (mites/others)
• Tobacco smoke (ETS)
• Solid fuel smoke
• Infections
• Outdoor exposures SO2, Ozone
• Occupational exposures
• Psychological stresses
• Drugs aspirin, betablockers, ACE inhibitors

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Pollen House-dust Mite
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Diagnosis

• Clinical Features
• Symptoms and triggers
• Physical Examination
• Investigations

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Clinical Feature of Asthma

• Generally episodic, and seasonal
• In some patients, continuous
• Mild and intermittent to severe and persistent
  forms
• Common symptoms Cough, chest tightness,
  wheezing and breathlessness expectoration.
• Early morning attacks
• Associated nasal symptoms Sneezing, rhinorrhoea,
  nasal blockade URC

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Physical Examination

• GPE during an attack
• Tachypnoea,
• Chest hyper-inflated,
• P. Note hyper-resonant
• Breath sounds decreased
• Wheezing/ rhonchi
• If severe Respir distress, cyanosis (rare),
  shock pulsus paradoxus etc.

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Investigations

• Chest X-Ray Normal or signs of
• hyperinflation pneumothorax
• lobar collapse, consolidation
• Demonstration of Variable air-flow obstruction
• Low PEF Reduced FVC, FEV1/FVC,
• PEF diurnal variations,
• Bronchodilator reversibility
• Airway hyper-responsiveness
• Biochemical investigations

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• Airway inflammation
• Blood and sputum eosinophilia
• Exhaled air nitric oxide levels
• Bronchial mucosal biopsy
• Presence of atopy
• Serum IgE levels
• Demonstration of specific antibodies
• Skin hypersensitivity tests

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Differential Diagnosis

• Chronic obstructive pulmonary disease
• Upper respiratory catarrhs
• Hyper-sensitivity pneumonias
• Hyper-eosinophilic syndromes
• Bronchiectasis
• Children Acute laryngo tracheo-bronchitis,
• bronchopneumonia, cystic fibrosis
• Foreign body aspiration

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All that wheezes isNot AsthmaandAll
asthmadoes not wheeze
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Asthma-like syndromes

• Exercise-induced asthma
• Occupational asthma
• Hyper-sensitivity pneumonia
• Eosinophilic bronchitis
• Eosinophilic syndromes
• Obesity-hypoventilation syndromes
• Drugs and diets

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Complications

• Acute exacerbations
• Acute respiratory failure
• Pneumothorax, pneumomediastinum, sub-cutaneous
  emphysema
• Respir infections, pneumonias
• Allergic broncho-pulmonary aspergillosis
• Airway remodelling, irreversible obstruction
• Tmt related complications Local, systemic

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Allergic Broncho Pulmonary Aspergillosis

• Hypersensitivity to aspergillus in the
  tracheo-bronchial tree in patients with chronic
  asthma.
• Clinical Features Severe attacks, sputum
  production hard brown plugs hemoptysis
• Radiology CXR and HRCT Fleeting opacities,
  typical patterns bronchiectasis
• Diagnosis Skin test Immediate delayed ve
• Sputum for aspergillus ve
• Serology ve
• Total Aspergillus specific
  IgE levels

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Goals of Asthma Management

1. Minimal (ideally no) symptoms
2. Minimal (or no) symptoms on exercise
3. Minimal need for relievers
4. No exacerbations
5. No limitation of physical activity
6. Normal (or near normal) PFT
7. Minimal side effects of drugs
8. Prevention of irreversible obstruction
9. Prevent asthma related mortality

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Asthma Pathophysiology
INFLAMMATION
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Targets for Treatment(Based on pathophysiology)

• 1.Symptom Treatment Cough Wheeze, Dyspnoea
• Treatment of Airflow Limitation
• 2. TREATMENT OF INFLAMMATION
• 3. Management of Airway Hyper-responsiveness
• 4. MANAGEMENT OF INDUCERS TRIGGERS
• Allergens, Chemical sensitizers, Virus
  infections
• Air pollutants, Allergens,
  Exercise, Cold Air, SO2 Particulates
• 5. Genetic manipulation?

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Anti-asthma drugs

• Bronchodilators (Relievers)
• Primary action on bronchial smooth
  muscles, relieve bronchospasm, produce
  symptomatic relief
• Anti-inflammatory drugs (Controllers)
• Reduce inflammation, improve airflow,
  reduce AHR, prevention of recurrent symptoms,
  prolonged relief

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Bronchodilators (Relievers)

• 1. Theophyllines
• 2. Sympathomimetics
• Beta agonists (Selective)
• Rapid acting ? 2 agonists(Salbutamol,
• Terbutaline)
• Long acting (Salmeterol, Formoterol)
• Oral short acting ?2 agonists
• 3. Anticholinergic/ muscarinic agents)
• Inhaled anticholinergics
• 4. Oral glucocorticoids

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Anti-inflammatory Drugs

• Corticosteroids
• Inhaled (Beclomethasone, Budesonide,
• Fluticasone, Mometasone,
  Triamcinalone)
• Oral (Prednisone, Prednisolone,
• Dexamethasone,
  Methylprednisolone)
• Parenteral (Hydrocortisone,
• Methylprednisolone,
  Dexamethasone etc)
• Immunosuppressants
• Immunomodulators

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Inhalational Treatment

• Preferred route for both controller and reliever
  therapy
• Advantages Local effect,
• immediate response
• Minimal dosage,
• few side effects
• Available as Dry powder (DPIs),
• Metered dose liquid
  inhalers MDIs)
• Nebulizers
• Devices Spacers (to increase drug delivery)

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Side effects of inhalation drugs

• Local side effects
• throat irritation,
• voice change, thrush (candida
• infection), vocal cord dysphonia
• Systemic side effects of drugs Rare
• may be growth retardation in
• young children
• cataracts, other steroid effects

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Metered Dose Inhalers
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Dry powder inhalers
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Managing Aggravating Factors

• Tmt of sinusitis and polyps
• Managing GE reflux
• Weight reduction
• Sleep disorder evaluation
• Tmt of psychological stress
• Management of VCD if any
• Reducing allergen load, dust, smoke/ETS, pets
  (etc.)

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Acute severe asthma

• Unable to complete a sentence in one breath
• RR gt 30/minute
• Use of accessory muscles of respiration
• HR gt 120/minute
• Pulsus paradoxus gt 25 mm Hg
• Extensive inspiratory and expiratory wheeze
• PEFR lt 50 personal best
• PaO2 lt 60 mm Hg, PaCO2 gt 45 mm Hg

GINA 2004
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Management of severe asthma

• Stabilization Oxygen, hydration
• Nebulized bronchodilators
• Oral/ parenteral corticosteroids
• Evaluate and treat confounding or
• exacerbating factors
• 5. If refractory to treatment, assisted
  ventilation may be required.

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Difficult situations

• Maintenance treatment
• Labile/Brittle asthma
• Steroid dependent
• Other comorbidities
• Specific situations
• Pregnancy
• Surgery
• Concurrent diseases and drugs
• Occupational asthma

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Prognosis

• Good, unless poorly controlled, severe and
  continuous with frequent exacerbation
• Compatible with normal life span and quality of
  life. Too many restrictions must be avoided.
• Irreversible airway obstruction in some with poor
  control remodelled asthma
• Some phenotypes of asthma are associated with
  risk of fatality Brittle asthma, Near fatal
  asthma, Steroid dependent asthma.

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SUMMARY

• Asthma is a common and important health
• problem at all ages, especially during
  childhood. It is
• characterized by an atopic state, airway
• hyper-responsiveness, obstruction, wheezing and
• breathlessness.
• Asthma has a genetic basis, but precipitated by
  multiple
• triggers such as allergens, infections and other
  agents. It is
• important to look for triggers/ causes of
• asthma for an effective control.
• Airway inflammation, a prominent feature in
• asthma, needs to be targeted with effective
  anti-
• inflammatory medication (primarily inhalational)
  to
• achieve asthma control.