Lecture 4 chest ASTHMA .pdf

Competency-based Medical Bachelor Program “CBMBP”  Semester: S6 Course name. Respiratory Title of Lecture bronchial asthma chest department Day/Date:...

Competency-based Medical Bachelor Program “CBMBP”  Semester: S6 Course name. Respiratory Title of Lecture bronchial asthma chest department Day/Date: 2024 Name of teacher: Ass.Prof ragia sharshar Affiliation : Ragia S. Sharshar Email : [email protected] Ground Rules  Bronchial Asthma By Ragia Sharshar ass.prof of Chest Diseases Faculty of Medicine Tanta University  ILOs i. To Determine definition of bronchial asthma ii. To review etiology of bronchial asthma iii. To illustrate pathogenesis of bronchial asthma iv. To illustrate Pathology of bronchial asthma v. To describe various Types of bronchial asthma vi. To determine clinical picture, investigation and complication of bronchial asthma vii. To Justify Proper managment options of bronchial asthma viii. To conclude …of of bronchial asthma. What is the bronchial asthma?  What is Bronchial asthma Is a common and potentially serious chronic disease that imposes a substantial burden on patients , their families and the community. It causes respiratory symptoms, limitation of activity , and flare-ups ( attacks) that sometimes require urgent health care and may be fatal  Definition Asthma is meaning difficulty in breathing. Asthma is a chronic inflammatory lung disease involving recurrent breathing problems: paroxysmal attacks of dyspnea, cough and wheezing. The characteristics of asthma are 3 airway problems: Obstruction, inflammation , hyperrespnsiveness. Etiology ?  Etiology Presence of risk factor may increase person's chance of developing a disease, as : Activity: called exercise – induced asthma. Diet: egg, fish, milk. Drugs: aspirin and pencillin. Family history: Urticaria, hayfever. Or many other things: Inhalants: Smoking, dust, pollens, fumes, leathers, moulds. Infection: septic focus, tonsillitis, sinusitis, bronchitis. Hormonal ex: attacks occur during pregnancy or menstruation or during menopause.  Etiology Genetics A parent can pass asthma on to their child. If one parent has asthma, there is a 25 percent chance that a child will develop asthma. Having two parents with asthma increase the risk to 50 percent. Many genes are involved in passing on asthma. These genes can interact with the environment to become active, although confirming these findings may require further research.  Etiology Atopy : Atopy is general class of allergic hypersensitivity that leads to allergic reactions in different parts of body that do not come in contact with an allergen. Examples include eczema, hay fever, and eye condition called allergic conjunctivitis. During atopy, body produces more immunoglobin (IgE) antibodies than usual in response to common allergens. Obesity Stress NB: The most common type of asthma is atopic asthma, and atopy plays a key role in its development. Environmental allergens lead to overproduction of IgE antibodies and trigger asthmatic reactions.  Asthma phenotypes The approaches to phenotyping asthma most commonly used to date include clinical, trigger-related, demographic and pathological factors. Most early attempts to define phenotypes were relatively one- dimensional and based on simple classifications such as age of onset or atopic/non-atopic.  Asthma endotype Allergic asthma or childhood asthma ( allergic rhinitis th2 dominant, eosinophilia, IL 4,13, IGE) Three major criteria personal atopic dermatitis parental asthma or sensitization to an aeroallergen or Two of the three minor criteria peripheral eosinophils >4% wheezing unrelated to the common cold  or sensitization to a food allergen  Allergic bronchopulmonary mycosis (ABPM) Characterized by hypersensitivity reaction to airway colonization by molds, especially Aspergillus fumigatus The main histological feature of ABPM is allergic (eosinophilic) mucin- harboring hyphae in the bronchi Clinically, ABPM is characterized by episodic bronchial obstruction and mucoid impaction, peripheral blood eosinophilia, elevated serum IgE levels, IgE and IgG antibodies specific for fungi  Aspirin-sensitive asthma (ASA) It almost always appears in adulthood and has a distinct clinical presentation, presenting after the intake of a nonsteroidal anti- inflammatory drug (NSAID ]. Severe and prolonged airway obstruction is characteristically associated with chronic/severe rhinosinusitis and nasal polyps (aspirin-exacerbated respiratory disease), peripheral blood eosinophilia, and raised urinary leukotrienes at baseline and post-aspirin challenge.  Asthma characteristics The characteristics of asthma are 3 airway problems: Obstruction, inflammation and hyperrespnsiveness.  Pathogenesis of BA Triggers of asthma Activate several inflammatory cells (mast cells, macrohpages, bronchial epithelial cells, eosinophils, platelets and neutrophils.) All these cells are responsible for release of soup of inflammatory mediators e.g.,: histamine, prostaglandins, leukotrienes, platelets activating factors, bradykinin, adenosine, serotonin, neurokinin, complement fragments and O2 radicals. These mediators cause: Bronchoconstriction. Microvascular leakage (oedema and exudate). Mucous hypersecretion. Bronchial hyperresponsiveness. EMG ASTHMA: DIAGNOSIS AND TREATMENT DECEMBER 2018 Clinical features Of BA  Clinical features of BA General signs: Local signs: Inspection Palpation Percussion Auscultation  Clinical features General signs: Local signs: Tachypnea. Hyperinflated chest , increased A.P diameter. Tachycardia. Prolonged exp. Phase. Pulsus paradoxus. Its magnitude Skin retraction over IC spaces with correlates with the severity of inspiration. asthma. Use of accessory m. Hyperresonant repercussion note. Inspiratory expiratory polymorphic wheezing. Diminished breath sounds as index of severe obstruction. Differential diagnosis Inflammation in Asthma & COPD Asthma COPD sensitizing agent Noxious agent Asthmatic COPD airway inflammation airway inflammation CD8 T lymphocyte& CD4 T lymphocyte& eosinophil macrophages& neutrophoil Airflow limitation Reversible Irreversible  DD Causes of asthmatic syndrome 1- Cardiac asthma 2- Renal asthma 3- Fibrosing asthma 4- Polyarteritis nodosa 5- Carcinoid tumours 6- loeffler’s syndrome Causes of paroxysmal dyspnea: 1.Tetany 2. Mediastinal syndrome 3.Myathenia crises 4.Poisoning 5.FB 6. Hysterical Chronic asthmatic bronchitis  Investigations 1. X Ray 2. Sputum 3. Blood picture 4. Test for allergy 5. ECG 6. PFT 7. Bronchial provocation test 8. Exercise test  Complication 1. Status Asthmaticus 2. COPD 3. Respiratory failure 4. Cor pulmonale 5. Pneumothorax 6. Allergic Aspergillosis 7. Complications of chronic cough Acute severe asthma Or Status asthmaticus  Acute severe asthma /Status asthmatics: Severe, progressive, prolonged attack of asthma which persists more than 6h. Despite full and adequate therapy of asthma. The patient is distress, tachypnea (30 min) and tachycardia (120 min) Pulsus paradoxicus lowering blood pressure because raised I.T.Pr interfere with the venous return. cyanosed, increased CO2, He may develop vascular collapse, Dehydration may occur due to loss of fluid from hyperventilation.  Treatment of BA Prophylactic Therapeutic  Bronchodilators Types Methods of administration Mechanism of action Side effects  Anti-inflammatory drugs Corticosteroids Leukotriene inhibitors Antihistaminics Methods of administration Mechanism of action Side effects  Other drugs used in BA Skin test Anti-IGE Cytotoxic drugs Others Long term management of BA: 1- Avoidance of precipitating factors 2- Inhaler therapy Classification asthma severity and treatment in stepwise approach : Step I intermittent Step2 Mild Step3 Moderate Step4 Severe Global Initiative for Asthma stepwise approach to control asthma symptoms and reduce risk.  Classification asthma severity and treatment in stepwise approach : Step 1: Step 2: Mild Intermittent: Treatment: Treatment: Short acting B2 agonists as Short acting inhaled B2 needed but not exceed 3-4 agonists when needed. time/ d. Na cromoglycate 1h. before Add inhaled corticosteroid exercise. daily, coromglycate or antileukotreines. Long acting B2 agonist for night symptoms.  Classification asthma severity and treatment in stepwise approach : Step 3: Moderate Step 4: Severe Treatment: Treatment: Short acting B2 agonists - Inhaled B2 agonists as needed. inhaled corticosteroids/ daily. Inhaled corticosteroids/ daily. Long acting B2 agonists or SR theophylline. Add SR aminophylline or long Add oral steroids on alternate days in acting B2 agonists for night the morning. symptoms and / or Treatment of precipitating factors and antileukoterienes. avoid allergen.  Management of acute exacerbation of BA: PaCO2 > 40 or PEF < 25% of baseline or deterioration despite maximal therapy  transfer to ICU. ICU treatment: Inhaled B2 agonsits every 30-60 min by nebulizer. Supplement with subcutaneous epinenphrine. IV aminophylline / protocol. Hydration 1-2L or 5% dextrose. Hydrocortisone 200 mg or more added to dextrose. O2 nasal catheter, or mask, or no invasive ventilation or intubation and mechanical ventilator. Global Initiative for Asthma stepwise approach to control asthma symptoms and reduce risk. Assessment of asthma control  Proposed personalized approach to asthma therapy. Susanne Meghdadpour, and Njira L Lugogo Respir Care 2018;63:759-772 (c) 2012 by Daedalus Enterprises, Inc.  References / Sources GINA report 2018 Contact … Ragia S. Sharshar Email : [email protected]