Presentation on Treatment of Bronchial Asthma | Jindal Chest Clinic

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Treatment of Bronchial Asthma
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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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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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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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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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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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Management of 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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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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Management of Asthma-like syndromes

• Exercise-induced asthma
• Occupational asthma
• Hyper-sensitivity pneumonia
• Eosinophilic syndromes
• Obesity-hypoventilation syndromes
• Drugs and diets induced asthma
• Allergic broncho-pulmonary aspergillosis (ABPA)

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Allergic Broncho Pulmonary Aspergillosis

• Colonization of aspergillus fungus in the
  tracheo-bronchial tree in patients with chronic
  asthma. Hypersensitivity to fungal antigens
• Clinical Features Severe attacks, sputum
  production hard brown plugs hemoptysis
• Radiology CXR and HRCT Fleeting opacities,
  typical patterns bronchiectasis (usually
  proximal)
• Diagnosis Skin test Immediate delayed ve
• Sputum for aspergillus ve
• Total Aspergillus specific
  IgE levels
• Treatment Oral corticosteroids, Antifungal
  (Itraconazole)

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Chronic Obstructive Pulmonary Disease (COPD)
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INSEARCH Prevalence in adults
Asthma 2-5, COPD 3-10

Jindal et al 2012
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Risk Factors for COPD
Host Factors Genes (e.g. alpha1antitrypsin
deficiency)
Hyper-responsiveness Exposure Tobacco
smoke Solid fuel
combustion Outdoor air
pollution Occupational
dusts and chemicals
Infections Socioeconomic
status








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Risk Factors for COPD

• Tobacco smoke
• Both cigarette and bidi smoking are equally
  responsible  
• Environmental Tobacco Smoke (ETS) exposure may
  also play a contributory role especially in
  nonsmoker individuals 
• Solid fuel combustion
• (dried dung, wood and crop residue for cooking
  and heating). It is responsible for a large
  number of COPD in the rural inhabitants in
  general and women in particular
• Outdoor air pollution

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Clinical Features Diagnosis

• Clinical History
• Cough
• Expectoration
• Dyspnoea
• Exacerbations
• Physical Examination
• Physical examination is rarely diagnostic in
  COPD.
• Physical signs of airflow limitation are rarely
  present until significant impairment of lung
  function has occurred.
• However, certain findings on clinical examination
  point towards the diagnosis of COPD.

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Findings supportive of COPD

• A barrel shaped chest with increased AP diameter
• Hyper-resonant percussion with obliteration of
  cardiac dullness
• Uniformly diminished intensity of Breath sound
  with a prolonged expiratory phase
• Fine inspiratory crepitations and rhonchi are
  commonly heard.
• Forced expiratory time (FET) will be prolonged to
  more than 6 sec.
• Patient may have pursed lip breathing.

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Differential diagnosis

• Bronchiectasis
• Asthma
• Tuberculosis
• Hypersensitivity pneumonias
• Eosinophilic bronchitis
• Other lung diseases

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Investigations

• Required for
• Exclusion of alternate diagnosis (D/D)
• Confirmation of diagnosis of COPD
• Reversibility test
• Assessment of severity of COPD
• Diagnosis of complications
• ABG analysis and assessing for LTOT

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• Sputum examination
• To exclude tuberculosis in suspected patients.
  Examine sputum smears for acid fast bacilli
  (AFB), at least thrice
• Chest X-ray
• Identify alternate diseases such as
  fibrocavitary tuberculosis, bronchiectasis, lung
  tumours
• Detect complications such as chronic cor
  pulmonale pneumothorax or pneumonia

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Confirmation of diagnosis Spirometry

• Spirometry remains the gold standard for
  confirmation and staging of COPD
• Spirometry should measure FVC FEV1 and the
  FEV1/FVC ratio
• The presence of a post bronchodilator FEV1lt80 of
  the predicted value in combination with a
  FEV1/FVClt70 confirms the presence of airflow
  limitation that is not fully reversible.

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MANAGEMENT

• I (Mild)- Short acting BDs
• II (Moderate)- Regular BD (one / more)
• III (Severe) - Bronchodilators
• - Inhaled corticosteroids
• - Rx of complications
• Tobacco cessation and pulmonary rehabilitation
  are important at all stages

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Guidelines on Smoking CessationThe 5A Strategy
for Physicians

1. ASK about tobacco use
2. ASSESS the status and severity of use
3. ADVISE to stop
4. ASSIST in smoking cessation
5. ARRANGE follow-up programme

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Bronchodilators

• Anticholinergics
• Tiotropium
• Ipratropium
• Beta-agonists
• Long acting Maintenance
• Short acting Rescue
• Combinations (12)
• Oral Theophyllines, PDE4 inhibitors

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Anticholinergics

1. Cause effective bronchodilatation
2. Reduce rate severity of acute exacerbations
3. Improve quality of life
4. Long acting
5. Side effects Dryness, blurred vision, urinary
   retention (if BPH)

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Corticosteroids

• Oral/parenteral for acute exacerbations
• Inhaled for moderate to severe COPD
• Improve lung function
• Reduce exacerbations
• Improve symptoms Q.O.L.
• Reduce airway reactivity
• Side effects
• Loss of bone mineral density
• Increased skin bruising

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Complications of COPD

• Acute exacerbations
• Severe airway obstruction
• Acute change in baseline lung function
• Marked exercise tolerance
• Nocturnal hypoxemia
• 2. Pulmonary hypertension and Chronic cor
  pulmonale
• 3. Respiratory failure

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Symptoms of COPD Exacerbation

• Increase in cough
• Chest pain
• Increase in breathlessness
• Increase in sputum volume and change in its
  colour (to green, yellow, blood streaked)
• Fever
• Increased tiredness
• Increase in oxygen requirement (for those on
  long-term oxygen therapy)

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Management of Acute Exacerbations

1. Increase the dose and/or frequency of current
   bronchodilator therapy
2. Add new bronchodilators
3. Bronchodilator nebulization
4. Parenteral theophyllines
5. Systemic glucocorticoids
6. Antibiotics for infections
7. Maintenance of oxygenation
8. NIV or Assisted Ventilation for refractory
   respiratory failure (Hypoxaemia and/ or
   hypercapnia)

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Supplemental Oxygen

• Hypoxemia common in hospitalized pts.
• Small increase in FiO2 - good response
• However, this can worsen hypercapnia
• due to
• Release of hypoxic vasoconstriction ? Increased
  dead-space
• Loss of hypoxic respiratory drive
• Domicilliary long term-term oxygen therapy for
  COPD with chronic respiratory failure

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Assisted Respir Supports

• Non-invasive ventilation (NIV) in case there is
  failure to respond to supportive therapy and
  controlled oxygen supplementation
• - Initiate as early as possible
• - RR gt 24 and hypercapnia with acidosis
• - (pH lt7.35) are the classic indications
• - No benefit in milder exacerbations
• Intubation and Mechanical ventilation if NIV is
  contraindicated, has failed, or is not tolerated

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Chronic Cor Pulmonale

• Definition Alterations in the structure and/or
  function of the right ventricle secondary to
  diseases of the lung, chest wall or lung
  vasculature (which are not secondary to the
  diseases of the left heart or congenital heart
  diseases).
• Manifests with features of pulmonary hypertension
  and right heart overload/ failure
• Generalized anasarca, congested liver, ascites,
  cyanosis, loud P-2, cardiomegaly (rt.)
• Diagnosis H/O COPD
• CXR, ECG, ECHO

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Treatment of cor pulmonale

• Long term oxygen therapy
• Removal of fluid retention diuretics
• Maintenance of CO2 levels
• Digoxin, if arterial fibrillation
• Vasodilators - may be hazardous (Lower systemic
  and pulm. BP)
• Treatment of COPD

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Other complications

• Rupture of blebs/bullae Pneumothorax,
  pneumomediastinum, subcutaneous emphysema
• Polycythemia (due to chronic hypoxemia)
• Increased coagulation problems
• - In situ thrombosis
• - Pulmonary thromboembolism
• 5. Hyperuricemia (and occasionally gout)
• 6. Systemic manifestations

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Systemic manifestations of COPD

• 1. General
• Wasting, weight loss,
• Nutritional anomalies, anemia
• 2. Musculoskeletal
• Skeletal muscle dysfunction,
• Osteoporosis
• Reduced exercise tolerance,
  performance
• 3. Cardiovascular
• Ischemic heart disease
• Cardiac failure, Stroke

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• 4. Endocrinal
• Diabetes,
• Metabolic syndrome
• Dysfunction of pituitary,
• thyroid, gonads and
  adrenals
• 5. Neuropsychiatric
• Depression
• Disordered sleep
• Anxiety
• Cognitive function decline

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Long term Maintenance and Prophylaxis Treatment

• Keep off smoking
• Bronchodilators
• Inhaled corticosteroids
• Use/avoidance of other drugs (e.g. antibiotics,
  mucolytics ,sedatives)
• Prophylactic vaccination (influenza)
• Pulmonary rehabilitation (multidisciplinary
  supports and management)

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