ASTHMA

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ASTHMA

• Victor Politi, M.D., FACP
• Medical Director, SVCMC School of Allied Health

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What is Asthma?

• Asthma is a chronic condition that occurs when
  the main air passages of the lungs, the bronchial
  tubes, become inflamed.
• The muscles of the bronchial walls tighten and
  extra mucus is produced, causing the airways to
  narrow.
• can lead to minor wheezing to severe difficulty
  in breathing.
• In some cases, breathing may be so labored that
  an asthma attack becomes life-threatening

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Definitions

• Asthma
• Reversible airway obstruction
• Airway inflammation
• Increased bronchial hyperresponsiveness
• Status Asthmaticus
• Severe airway obstruction developing over
  days-weeks

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The Respiratory System
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Pathophysiology

• Hallmark of Asthma -Bronchial wall
  Hyperresponsiveness
• Early Phase Asthma Reaction
• Bronchoconstriction
• Antigenic Stimulation of bronchial wall
• Mast Cell Degranulation releases
• Histamine
• Chemotactics
• Proteolytics
• Heparin
• Smooth Muscle Bronchoconstriction

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Pathophysiology

• Late Phase Asthma Reaction Bronchial
  Inflammation
• Inflammatory Cells Recruited
• Neutrophils
• Monocytes
• Eosinophils
• Release Cytokines, Vasoactives, Arachidonic acid
• Epithelial and Endothelial Cell inflammation
• Release of Interleukin 3-6, TNF, Interferon-gamma
  

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Risk Factors

• Family History
• One parent with asthma up to 25 risk for child
• Two parents with asthma up to 50 risk for child
  
• Parental tobacco use
• Associated aspirin or NSAID allergy
• Classic Triad
• Asthma, Nasal polyps, Aspirin allergy
• RSV Bronchiolitis history
• Strongly associated with later development of
  asthma
• Strenuous exercise in areas of high ozone
  (pollution)

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Types of Asthma

• Extrinsic Asthma (Allergic)
• Intrinsic Asthma (Non-allergic)
• Mixed Asthma (Extrinsic and Intrinsic)
• Occupational Asthma
• Drug Induced Asthma
• Aspirin-induced Asthma
• NSAID-induced Asthma
• Exercise Induced Asthma
• Cough Variant Asthma
• Very common! (Especially in children)

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Asthma Statistics

• For reasons no one quite understands, the number
  of asthma cases has risen dramatically during the
  past decade, especially among children living in
  the inner city.
• Approximately 14 million Americans have asthma,
  including more than 6 million children.
• Asthma is the most common chronic illness of
  childhood.
• Among young children, asthma is more common in
  boys than in girls.
• After puberty asthma becomes more common in girls

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Intrinsic Asthma Non-allergic asthma

• Pathophysiology
• Non-IgE, Non-allergic asthma
• Precipitating Factors
• Irritant exposure
• (Air Pollution, Fumes, Perfumes, Household
  cleaning agents, Insecticides, paint, tobacco,
  cold air
• Infection
• URI, purulent rhinitis, acute sinusitis
• GERD
• Epidemiology
• Much more common in adults than children
• Onset age over 40 years old

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Extrinsic Asthma Allergic Asthma

• Pathophysiology
• IgE mediated response to allergens
• Immediate allergic reaction
• Late-phase allergic reaction
• Causes
• Indoor allergens
• House Dust mites (most common extrinsic
  allergen)
• Animal proteins (animal dander)
• Mold spores
• Cockroaches
• Outdoor allergens
• Pollens , mold spores
• Epidemiology
• Much more common in children than adults
• Age Onset under 40 years old

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Asthma Triggers
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Asthma Triggers
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Asthma Triggers
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All Asthma attacks give a warning

• Warning signs and symptoms for adults can
  include
• Increased shortness of breath or wheezing
• Disturbed sleep caused by shortness of breath,
  coughing or wheezing
• Chest tightness or pain
• Increased need to use bronchodilators
  medications that open up airways by relaxing the
  surrounding muscles
• A fall in peak flow rates as measured by a peak
  flow meter

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All Asthma attacks give a warning

• Warning signs and symptoms for children may
  include
• An audible whistling or wheezing when the child
  exhales
• Coughing, especially if the cough is frequent and
  occurs in spasms
• Waking at night with coughing or wheezing
• Shortness of breath, which may or may not occur
  when the child exercises
• A tight feeling in the child's chest

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Asthma and Other Conditions

• Differentiating between asthma and chronic
  obstructive pulmonary disease (COPD) such as
  emphysema and chronic bronchitis can be
  especially challenging.
• Asthma and COPD each cause similar symptoms.
• Not uncommon for older adults especially
  longtime smokers to have both conditions.
• Various tests including skin or blood tests for
  allergies, and spirometry can help determine
  whether asthma is present.

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What is cardiac asthma?

• Cardiac asthma isn't actually asthma.
• It refers to the wheezing that's caused by CHF
• Excess fluid in the lungs (pulmonary edema)
  associated with heart failure causes signs and
  symptoms such as shortness of breath, coughing
  and wheezing, which mimic asthma

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Exercise Induced Asthma

• Exercise-induced asthma or exercise-induced
  constriction of the bronchial tubes
  (bronchospasm)
• a condition in which the airways narrow
  significantly during vigorous exercise.
• Typical Symptoms
• Cough, Wheezing, Shortness of breath, Chest
  tightness
• Typically symptoms present about 10 minutes after
  stopping exercise

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Exercise Induced Asthma

• Exercise-induced wheezing or shortness of breath
  is typical for people who have chronic asthma.
• But exercise-induced wheezing or shortness of
  breath can occur when sensitive airways
  constrict when exercising, especially when
  combined with cold air, low humidity or
  pollution.

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Chronic Asthma or Exercise Induced Asthma

• Basic difference between chronic asthma and
  exercise-induced asthma
• People with exercise-induced asthma have symptoms
  only with physical activity.
• People with chronic asthma often have
  exercise-induced wheezing or shortness of breath,
  but they may have asthma symptoms at other times
  as well.

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Exercise Induced Asthma - Medications

• The most common medications for exercise-induced
  asthma are bronchodilators, which are taken about
  15 to 30 minutes before exercising
• Medications Include
• Albuterol (Proventil, Ventolin)
• Pirbuterol (Maxair)
• Ipratropium and albuterol combination (Combivent)
  

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What's the difference between asthma and COPD?

• similar symptoms but very different
• Asthma causes reversible lung inflammation,
• COPD causes irreversible lung damage
• It's important to distinguish between the two
  conditions because they're treated differently

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What's the difference between asthma and COPD?

• Smoking history. Asthma may occur in nonsmokers
  as well as in smokers. But COPD is usually
  associated with a long history of smoking

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What's the difference between asthma and COPD?

• Symptoms
• Periodic wheezing and chest tightness, especially
  at night, is typical of asthma.
• COPD is more likely to cause a daily morning
  cough that produces mucus.
• In COPD, patients may develop a permanently
  expanded barrel chest because too much air is
  trapped in the lungs.

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Cough Variant Asthma

• Chronic cough
• Cough gt 3 weeks
• Nonproductive
• Usually nocturnal but can occur anytime
• Occur any age group
• PFTs normal
• Rule out other causes of chronic cough
• TX
• Similar to common forms of asthma

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Asthma EvaluationDifferential Diagnosis

• General
• All that wheezes is not asthma!!
• However most recurrent cough and wheeze is asthma
  
• Upper airway disease
• Allergic rhinitis
• sinusitis
• Large airway obstruction
• Foreign body
• Vocal cord dysfunction
• Vascular rings of laryngeal webs
• Laryngotracheomalacia
• Tracheobronchial-stenosis
• Enlarged lymph node or tumor

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Asthma EvaluationDifferential Diagnosis

• Small Airway obstruction
• Viral Bronchiolitis
• Bronchiolitis obliterans
• Cystic Fibrosis
• Bronchopulmonary dysplasia
• Heart disease
• Other Causes
• Psychogenic cough
• GERD
• ACE inhibitors

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Asthma EvaluationHistory

• General History is not always accurate
• Confirm with PFTs every 3-6 month
• Patient may underplay symptoms
• 10 of patients do not recognize severe Symptoms
  of their asthma
• Age of onset and asthma diagnosis
• Past history of respiratory failure or intubation
  
• Recognize cohorts at additional risk
• Elderly
• Pregnancy

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Asthma EvaluationHistory

• History of early life injury to airways
• Bronchopulmonary Dysplasia
• Parental smoking
• Disease progression
• Present management and response
• Frequency of systemic corticosteroid use
• History steroid-induced complications
• Comorbid conditions
• Chronic sinusitis
• Assess in all asthma patients
• Consider empiric treatment if refractory asthma

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Asthma EvaluationHistory

• Family History (any asthma, allergic rhinitis,
  etc.)
• Social History
• Home characteristics
• Heating and cooling system
• Wood burning stove
• Humidifier
• Carpeting over concrete
• Smokers in home
• Daycare and school situation impacting compliance
  

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Asthma EvaluationSigns Respiratory distress

• Tachypnea
• Dyspnea
• Anxiety
• Accessory Muscle Use
• Intercostal muscle use
• Sternocleidomastoid use
• Scalenes Muscle use
• Cyanosis in severe cases (lips)
• Tachycardia

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Asthma EvaluationRadiology chest x-ray

• Indications
• Initial asthma diagnosis
• Low yield in acute asthma exacerbations
• Abnormal findings at presentation 5
• Abnormal findings if no improvement in 12 hours
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• Status Asthmaticus or no acute asthma improvement
  
• Excludes other diagnoses
• CHF
• Pneumonia
• Excludes complications
• Pneumothorax
• Pneumomediastinum

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Asthma EvaluationLabs

• ABGs
• Hypoxemia
• Hypercarbia (or normal CO2) with decompensation
• CBC
• Eosinophilia may be present
• Increased Levels of IgE may be present
• Sputum Sample
• May show casts of small airways
• Thick mucoid sputum
• Curschmann's spirals
• Charcot-Leyden crystals

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Asthma EvaluationOther Diagnostic Tests

• PFTs Pulmonary Function Testing
• Spirometry
• Methacholine Challenge

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What are PFT's?

• Pulmonary function testing is one of the basic
  tools for evaluating a patient's respiratory
  status.
• In patients with suspected pulmonary disease, it
  is often the first diagnostic test employed in
  the work up.
• Pulmonary function tests (PFT's) are also used
  for pre-operative evaluation, managing patients
  with known pulmonary disease, and quantifying
  pulmonary disability

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PFT- Spirometry

• A versatile test of pulmonary physiology.
• Reversibility of airways obstruction can be
  assessed with the use of bronchodilators.
• After spirometry is completed, the patient is
  given an inhaled bronchodilator and the test is
  repeated.
• The purpose of this is to assess whether a
  patient's pulmonary process is bronchodilator
  responsive by looking for improvement in the
  expired volumes and flow rates

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PFT- Spirometry

• spirometry can be used to detect the bronchial
  hyperreactivity that characterizes asthma.
• By inhaling increasing concentrations of
  histamine or methacholine, patients with asthma
  will demonstrate symptoms and produce spirometric
  results consistent with airways obstruction at
  much lower threshold concentration than normal

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PFT- Spirometry

• Normal values vary depending on gender, race,
  age, and height.
• It is therefore not possible to interpret PFT's
  without such information.
• There is no single set of standard reference
  values, however, and "normal" varies with the
  reference value used in each laboratory

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PFT- SpirometryDefinitions

• FEV1 - forced expiratory volume 1 - the volume of
  air that is forcefully exhaled in one second.
• FVC - forced vital capacity - the volume of air
  that can be maximally forcefully exhaled
• FEV1/FVC - ratio of FEV1 to FVC, expressed as a
  percentage
• FEF25 - 75 - forced expiratory flow - the average
  forced expiratory flow during the mid (25 - 75)
  portion of the FVC
• PEF - peak expiratory flow rate - the peak flow
  rate during expiration

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PFT- Spirometry

• In general, a gt 12 increase in the FEV1 (an
  absolute improvement in FEV1 of at least 200 ml)
  or the FVC after inhaling a beta agonist is
  considered a significant response.
• However, the lack of an acute bronchodilator
  effect during spirometry does not exclude a
  response to long term therapy

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Mild Obstruction Flow Volume
                        
Normal Flow Volume Loop                        
    
                                              
        
                                         
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Asthma Medications

• Two general types of asthma medications
• Anti-inflammatory
• Corticosteroids reduce swelling mucous in
  airways
• Bronchodilators
• Relax muscle bands around airways allowing more
  air to flow, also increases mucous movement

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Quick Relief Medications

• Short acting beta-agonists
• (bronchodilators that are the drug of choice to
  relieve asthma attack and prevent
  exercise-induced asthma symptoms)
• Anticholinergics
• (bronchodilators used in addition to short-acting
  beta agonists when needed or as an alternative to
  these drugs when needed)
• Systemic corticosteroids
• (anti-inflammatory drug used in an emergency to
  get rapid control of the disease while initiating
  other treatments and to speed recovery)

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Status AsthmaticusEmergency Management of
Asthma Exacerbation
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Indications of severe attack

• Breathless at rest
• Hunched forward
• Talking in words rather than sentences
• Agitated
• Peak flow rate lt than 60 of normal

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Status Asthmaticus

• A medical emergency in which symptoms are
  refractory to initial bronchodilator therapy
• Symptoms chest tightness, rapidly progressive
  shortness of breath, dry cough, and wheezing.
• Typically, patients present a few days after the
  onset of a viral respiratory illness, following
  exposure to a potent allergen or irritant, or
  after exercise in a cold environment.

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Asthma Exacerbation Management

• Step 1 Initial Assessment
• Routine asthma evaluation as previously mentioned
  
• Vital Signs (heart rate, respiratory rate, Peak
  Expiratory Flow Rate (PEF) or FEV1
• O2 saturation
• Respiratory Status
• Lung auscultation
• Assess accessory muscle use
• Chest x-ray has low yield in acute exacerbations
• ABGs

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Asthma Exacerbation Management

• Inhaled short acting Beta Agonist (nebulized)
• One dose up to every 20 minutes for one hour
• Anticholinergic (Ipratropium bromide or Atrovent)
  
• Add to nebulized albuterol
• Indication FEV1 or PEF lt50 of predicted
  (Severe)
• Systemic Corticosteroid (PO or IV Indications)
• Severe episode (FEV1 or PEF lt50 predicted)
• No immediate response
• Oral corticosteroid recently taken by patient
• Oxygen indications
• Adults O2 saturation lt91
• Children 02 saturation lt96

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Additional measures for severe exacerbation

• Nebulized Albuterol w/Atrovent
• hourly or continuous
• Systemic corticosteroid
• Epinephrine 0.01 mg/kg up to 0.3 mg SC
• May be repeated every 5 minutes
• Oxygen 100 (warm, humidified) by non-rebreather
  mask
• Two Intravenous Lines
• Consider
• Aminophylline or Theophylline
• Magnesium 40 mg/kg up to 2 grams IV for 1 dose
• Rapidly effective in pediatric asthma
  exacerbations
• Also shown effective in severe adult acute asthma
  
• Some studies question benefit

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Additional measures for severe exacerbation
Intubation/mechanical ventilation

• Intubation is best done semi-electively before
  crisis
• Intubation criteria are based on clinical
  judgment
• Oral intubation is preferred
• Lower resistance and easier suctioning
• Lower incidence of sinusitis
• Indications
• Impending or actual respiratory arrest
• Extreme fatigue
• Altered mental status
• Significant respiratory distress
• Severe respiratory acidosis metabolic acidosis

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Medications To Be Wary Of with Asthma Patients

• Many adults take multiple prescription and
  over-the-counter medications to treat a variety
  of conditions. Some medications may trigger or
  worsen asthma symptoms.
• Angiotensin-converting enzyme (ACE) inhibitors
• Wont directly trigger asthma, can produce
  persistent cough causing increased wheezing
• Beta blockers
• NSAIDs
• can trigger severe and even fatal asthma attacks

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Asthma Management Goals
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Asthma Management Goals

• Medical professionals need to be alert to the
  signs/symptoms of asthma
• They must be able to treat asthma cases in a
  timely manner to avoid worsening of the condition
  and/or the development of status asthmaticus

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• Questions?