Treatment of Bronchial Asthma PDF

Treatment of Bronchial Asthma  Definition of Asthma ⚫ Chronic inflammatory disorder with intermittent narrowing of the airways. ⚫ Or a condition characterized by wide variations, over short periods of time, in the resistance to flow in the intrapulmonary airways. December 24...

Treatment of Bronchial Asthma  Definition of Asthma ⚫ Chronic inflammatory disorder with intermittent narrowing of the airways. ⚫ Or a condition characterized by wide variations, over short periods of time, in the resistance to flow in the intrapulmonary airways. December 24 2  Factors in the Treatment Strategy Asthma is a chronic condition The goal of therapy is normal function The Condition is heterogeneous in terms of: ▪ Cause or trigger mechanism. ▪ Extent of bronchoconstriction and ▪ Degree of inflammation. The course is unpredictable. Therapy must be individualized. December 24 3  Risk of Not Treating Asthma ⚫ Poor or no control of the patient’s asthma. ⚫ Accelerated decline in the function of the patient’s lungs ⚫ Increased number of attacks of asthma. ⚫ Poorer response to therapy if started late. ⚫ Increased mortality from asthma. December 24 4  Goals of Therapy in Asthma Minimal symptoms even during sleep. No, or infrequent, acute episodes. No ED visits or missed days in school or work. Rare need for beta-agonist inhaler therapy. No limitation of activities – even sports. Peak flow rate variability less than 20%. No or minimal adverse effects from drugs. December 24 5  Pathogenesis ⚫Early Asthmatic Response: Allergens can provoke IgE production. The tendency to produce IgE is genetically determined. Re-exposure to the allergen causes antigen- antibody interaction on the surface of the mast cells leading to: Release of stored mediators. Synthesis of other mediators. Also, activation of neural pathways Prevented by bronchodilators. December 24 6  Pathogenesis ⚫ Late Asthmatic Response: 4-5 hours later. More sustained phase of bronchoconstriction. Influx of inflammatory cells and an increase in bronchial responsiveness. The mediators here are cytokines produced by TH2 lymphocytes, especially interleukins 5, 9, and 13. These will stimulate IgE production by B lymphocytes, and directly stimulate mucus production. 7 December 24 8 December 24 9  Simplified view of allergic inflammation in the airways. December 24 10  Histopathology of a small airway in fatal asthma December 24 11  Asthma Triggers December 24 12  Asthma Triggers Exercise / cold air Cigarette smoke Stress / anxiety situations Animal dander's (cats, dogs etc..) Allergens (grass, trees, molds, cockroach) Pollutants (sulfur dioxide, ozone, etc…) Fumes/toxic substances Medications (ASA, NSAID’s, others) December 24 13 Diagnosis of Asthma - Subjective ✓ Cough - usually in spasms and to the point of vomiting - nighttime worse than daytime. ✓ Cough may follow exposure to cold air, exercise, a URI (common cold), or allergen ✓ Dyspnea > cough or wheezing > sputum. ✓ Past history of bronchiolitis as a child ✓Family history of asthma is common December 24 14  Diagnosis of Asthma - Objective Diminished Peak Expiratory Flow Rate (PEFR) Reduced mean and Forced Expiratory Flow Rate (FEFR) Reversibility with Bronchodilators Heightened response to Methacholine Test. Increase in expired Nitric Oxide Increase in Inflammatory Mediators and their metabolic products in body fluids December 24 15 Myths and Misconceptions ✓ Patient and physician “Steroid-o-phobia”. ✓ Asthma is an emotional illness. ✓ Asthma is an acute disease. ✓ Asthma medications are addictive. ✓ Asthma medications become ineffective if they are used regularly. ✓ Asthma is not a fatal illness / It does not kill. December 24 Munir Gharaibehm MD, PhD, MHPE 16 Survey of the changing therapy of asthma by decade 1960’s  Aminophylline, Epinephrine,  Ephedrine 1970’s  Beta-agonists, Theophyllines, Beclomethasone, Cromolyn,  Ipratropium December 24 17 Survey of the changing therapy of asthma by decade 1980’s Beta-agonists, Inhaled Corticosteroids, Cromolyn, Ipratropium 1990’s Inhaled Corticosteroids, Beta- agonists, Theophylline, Leukotriene Inhibitors December 24 18 Survey of the changing therapy of asthma by decade 2000’s  Corticosteroids + LABA, LTRAs, Theophylline, Cromolyn, Ipratropium, Tiotropium 2010’s  Prevention including gene therapy. December 24 19 December 24 20 Step-wise approach to asthma therapy Inhaled Long-acting Beta-2 Agonists (LABA) December 24 21 Inhaled Corticosteroids(ICS) (OCS) oral Corticosteroids  Relievers / Controllers Quick relief medications: Inhaled Short acting Beta-2 Agonists Inhaled Anticholinergics Systemic Corticosteroids Long-term control medications: Topical (inhaled) Corticosteroid Inhaled Cromolyn Na and Nedocromil Oral Methylxanthines (Theophyllines) Inhaled Long-acting Beta-2 Agonists (LABA) Oral Leukotriene modifiers (LTRA) December 24 22