MANAGEMENT OF MANAGEMENT OF BRONCHIAL BRONCHIAL ASTHMAASTHMA

Dr. Aswini Kumar MohapatraDr. Aswini Kumar Mohapatra Professor & HeadProfessor & Head Pulmonary MedicinePulmonary Medicine

MANAGEMENT OF MANAGEMENT OF ASTHMAASTHMA1. 1. patient educationpatient education -- pt.must understand the nature of the pt.must understand the nature of the

underline disease condition and its underline disease condition and its treatmenttreatment

pt. must appreciate differences between pt. must appreciate differences between reliever (bronchodilator) and preventer reliever (bronchodilator) and preventer (anti-inflammatory) medications(anti-inflammatory) medications

proper handling of inhaler devicesproper handling of inhaler devices use of peak flow meter- objective use of peak flow meter- objective

measure of airway obstructionmeasure of airway obstruction

2.2. avoidance of precipitating factorsavoidance of precipitating factors -- identification of agents causing identification of agents causing

exacerbationexacerbation measures to be taken to prevent or measures to be taken to prevent or

reduce allergen exposure like house hold reduce allergen exposure like house hold petspets

DesensitizationDesensitization -- repeated injections of repeated injections of allergens given to produce blocking allergens given to produce blocking antibody of IgG type to prevent the antibody of IgG type to prevent the allergens from binding to specific IgE on allergens from binding to specific IgE on mast cellsmast cells

Classif ication of asthma severity-Classif ication of asthma severity- Useful in directing asthma therapy and Useful in directing asthma therapy and

identifying pts.at risk for developing life identifying pts.at risk for developing life threatening asthma attacks threatening asthma attacks

Pt’s clinical features before treatment used Pt’s clinical features before treatment used to classify the pt.to classify the pt.

Mild intermittentMild intermittent Mild persistentMild persistent Moderate persistentModerate persistent Severe persistentSevere persistent

Approach to long-term treatmentApproach to long-term treatment – –Goals-Goals- minimise chronic symptoms that minimise chronic symptoms that

impair normal activity,prevent recurrent impair normal activity,prevent recurrent exacerbations, minimise repeated hospital exacerbations, minimise repeated hospital admissionsadmissions

Pharmacological agents for asthmaPharmacological agents for asthma – – Divided into -Divided into - long term control medicationslong term control medications Quick relief medicationsQuick relief medicationsMode of delivery of medications – Mode of delivery of medications – Oral,MDI,DPIOral,MDI,DPI

AA .. long-term control medications long-term control medications – – 1. A1. A nti- inflammatory agentsnti- inflammatory agents -- Corticosteroids -Corticosteroids - most potent,effective most potent,effective Reduce acute and chronic inflammation, Reduce acute and chronic inflammation,

improvement in airflow, decrease airway improvement in airflow, decrease airway hyper responsiveness, less airway hyper responsiveness, less airway remodelingremodeling

Inhaled corticosteroids preferred for long Inhaled corticosteroids preferred for long term control of asthma and first line agents term control of asthma and first line agents for persistent asthmafor persistent asthma

Inhaled medications decrease local Inhaled medications decrease local side effects-cough, dysphonia, side effects-cough, dysphonia, oropharyngeal candidiasisoropharyngeal candidiasis

Systemic corticosteroids (oral, Systemic corticosteroids (oral, parenteral)-prompt control of asthma parenteral)-prompt control of asthma during exacerbationsduring exacerbations

Preferably given alternate day therapyPreferably given alternate day therapy

2. 2. long acting bronchodilatorslong acting bronchodilators -- a. a. Mediator inhibitorsMediator inhibitors -- Cromolyn sodium, nedocromil- prevent Cromolyn sodium, nedocromil- prevent

asthma symptoms and improve airway asthma symptoms and improve airway function in mild persistent ,exercise function in mild persistent ,exercise induced asthmainduced asthma

Modulate mast cell mediator release and Modulate mast cell mediator release and eosinophil recruitmenteosinophil recruitment

bb . . ßß 22 adrenergic agents adrenergic agents -- Long acting Long acting ßß22 agonists- agonists-

salmeterol , formoterol salmeterol , formoterol Long duration of action - 12 hrs.Long duration of action - 12 hrs. Indicated for long term control of Indicated for long term control of

asthma symptoms, nocturnal asthma symptoms, nocturnal symptoms, prevention of exercise symptoms, prevention of exercise induced bronchospasminduced bronchospasm

c. c. Phosphodiesterase inhibitorsPhosphodiesterase inhibitors – – Theophyll ine -Theophyll ine - anti-inflammatory anti-inflammatory

properties,enhance mucocilliary properties,enhance mucocilliary clearance,strenghen diaphragmatic clearance,strenghen diaphragmatic contractilitycontractility

Theophylline serum conc. to be monitored Theophylline serum conc. to be monitored regularly because of its narrow therapeutic regularly because of its narrow therapeutic windowwindow

d. d. Leukotriene modifiers Leukotriene modifiers -- Newest classNewest class Leukotriene mediators cause contraction of Leukotriene mediators cause contraction of

airway smooth muscle ,increase vascular airway smooth muscle ,increase vascular permeability, mucus secretionpermeability, mucus secretion

Montelukast, zafirlukastMontelukast, zafirlukast

e. e. DesensitizationDesensitization -- Immunotherapy for specific allergenImmunotherapy for specific allergen Applicable for selected pts. in whom Applicable for selected pts. in whom

exacerbation of symptoms on exacerbation of symptoms on exposure to allergensexposure to allergens

f. f. Miscellaneous agentsMiscellaneous agents -- corticosteroid-sparing anti-inflammatory corticosteroid-sparing anti-inflammatory

agents :agents :methotrexate, cyclosporine ,iv methotrexate, cyclosporine ,iv

immunoglobulin, goldimmunoglobulin, gold

B. B. Quick rel ief medicationsQuick rel ief medications – – 1. 1. ßß -adrenergic agonists -adrenergic agonists -- Short acting inhaled Short acting inhaled ßß22 agonists most effective agonists most effective

bronchodilators during exacerbationsbronchodilators during exacerbations Relax airway smooth muscles – prompt Relax airway smooth muscles – prompt

increase in airflowincrease in airflow Cause tachycardiaCause tachycardia Currently available short acting Currently available short acting ßß22 agonists- agonists-

albuterol,pirbuterol,terbutalinealbuterol,pirbuterol,terbutaline

2. 2. AnticholinergicsAnticholinergics -- Reverse vagally mediated Reverse vagally mediated

bronchospasmbronchospasm Decrease mucus gland hyper Decrease mucus gland hyper

secretion in asthmasecretion in asthma Ipratopium bromide useful adjunct to Ipratopium bromide useful adjunct to

inhaled short acting inhaled short acting ßß22 agonists agonists

C.C. other medicationsother medications – – Monoclonal antibodiesMonoclonal antibodies -- recombinant humanized monoclonal antibody recombinant humanized monoclonal antibody

that binds with free IgE- that binds with free IgE- OmlizumabOmlizumab blocks its interaction with mast cells and blocks its interaction with mast cells and

basophilsbasophils given subcutaneously 2- 4 times weeklygiven subcutaneously 2- 4 times weekly AntibioticsAntibiotics – – prescribed during exacerbationsprescribed during exacerbations yellow or green sputumyellow or green sputum

Management of chronic persistent Management of chronic persistent asthma-asthma-

Treatment is step up or step down as Treatment is step up or step down as requiredrequired

MDI – MDI – inhaler devices should be used containing inhaler devices should be used containing chlorofluorocarbon(CFC)/hydroflurocarbon(HFA) chlorofluorocarbon(CFC)/hydroflurocarbon(HFA) as propellantsas propellants

Step wise managementStep wise management (5 steps) (5 steps)

Step-1Step-1 occasional use of inhaled occasional use of inhaled short short acting acting ßß22 agonists agonists

Step-2Step-2 regular inhaled anti-inflammatory regular inhaled anti-inflammatory agentsagents

Step-3 Step-3 high dose inhaled corticosteroids, or high dose inhaled corticosteroids, or low dose inhaled corticosteroids low dose inhaled corticosteroids

+ + long actinglong acting ßß22 agonists agonists Step-4Step-4 high dose inhaled corticosteroids high dose inhaled corticosteroids

and regular bronchodilators and regular bronchodilators Step-5Step-5 step-4 + regular oral corticosteroid step-4 + regular oral corticosteroid

therapy therapy

Step-1 : Step-1 : short acting bronchodilators i.e salbutamol short acting bronchodilators i.e salbutamol or terbutaline used by inhalation as required for or terbutaline used by inhalation as required for relief of occasional symptomsrelief of occasional symptoms

If pt. uses If pt. uses ßß22 agonists > once daily - step-2 agonists > once daily - step-2

Step-2 : Step-2 : inhaled inhaled ßß22 agonists used as required agonists used as required + + regular inhaled steroids (beclomethasone, regular inhaled steroids (beclomethasone, budesonide) up to 800µg dailybudesonide) up to 800µg daily

Step-3 : Step-3 : inhaled corticosteroids in the dose of 800-inhaled corticosteroids in the dose of 800-2000 µg daily + a long acting 2000 µg daily + a long acting ßß22 receptor agonist receptor agonist (salmeterol or formoterol)(salmeterol or formoterol)

salmeterol- 6 µg 12 hrly } used with spacersalmeterol- 6 µg 12 hrly } used with spacer formoterol- 50 µg 12 hrly } formoterol- 50 µg 12 hrly }

Step-4 :Step-4 : high dose inhaled corticosteroids high dose inhaled corticosteroids + + use of use of regular bronchodilatorsregular bronchodilators

a.a. inhaled long acting inhaled long acting ßß22 agonists agonists b.b. leukotriene receptor antagonists leukotriene receptor antagonists

(montelukast, zafirlukast)(montelukast, zafirlukast) c.c. inhaled ipratropium or oxitropium bromide inhaled ipratropium or oxitropium bromide d.d. long acting oral long acting oral ßß22 receptor agonists receptor agonists

(sustained release salbutamol or terbutaline)(sustained release salbutamol or terbutaline) e.e. high dose inhaled high dose inhaled ßß22 receptor agonists receptor agonistsStep-5 : Step-5 : step-4 plus step-4 plus regular prednisoloneregular prednisolone

tablets to control symptoms as a single daily tablets to control symptoms as a single daily dose in the morningdose in the morning

MANAGEMENT OF ACUTE MANAGEMENT OF ACUTE SEVERE SEVERE ASTHMAASTHMA Aims of management- to prevent death, restore Aims of management- to prevent death, restore

pulmonary function to the ptpulmonary function to the pt `̀s best as quickly as s best as quickly as possiblepossible

Immediate assessment of acute severe Immediate assessment of acute severe asthma-asthma-

features of severityfeatures of severity -- Pulse rate > 110 per min.Pulse rate > 110 per min.

Pulsus paradoxusPulsus paradoxus Unable to speak in sentencesUnable to speak in sentences PEF < 50% of expectedPEF < 50% of expected

Life-threatening features-Life-threatening features- Can not speakCan not speak Central cyanosisCentral cyanosis Exhaustion, confusion, reduced conscious Exhaustion, confusion, reduced conscious

levellevel BradycardiaBradycardia Silent chestSilent chest Unrecordable PEFRUnrecordable PEFR

ABG in l ife- threatening asthmaABG in l ife- threatening asthma -- A normal or high COA normal or high CO22 tension tension Severe hypoxemiaSevere hypoxemia A low pHA low pH

Immediate treatment-Immediate treatment- OxygenOxygen –– - High conc. usually 60%- High conc. usually 60% - Does not cause CO- Does not cause CO2 2 retention in retention in

asthmaasthma High dose of inhaled High dose of inhaled ßß 22 agonistagonist -- - - ßß22 agonists should be nebulised with O agonists should be nebulised with O 22

- Salbutamol (2.5-5mg) or terbutaline (5-- Salbutamol (2.5-5mg) or terbutaline (5-

10mg)given initially repeated within 30 10mg)given initially repeated within 30 minsmins

- MDI + large vol. spacer- MDI + large vol. spacerSystemic corticosteroidsSystemic corticosteroids –– Oral Prednisolone 30-60 mg or i.v Oral Prednisolone 30-60 mg or i.v

hydrocortisone if the pt. is unable to hydrocortisone if the pt. is unable to swallow given initially swallow given initially

Subsequent managementSubsequent management –– Pt. must be closely supervised, OPt. must be closely supervised, O22 therapy therapy

continuedcontinued

Continued managementContinued management --If features of severity persistsIf features of severity persists - - Iptratropium bromide 0.5 mg added to Iptratropium bromide 0.5 mg added to

nebulised nebulised ßß22 agonist agonist Continue nebulised Continue nebulised ßß22 agonist treatment agonist treatment

every 15-20 mins.as necessaryevery 15-20 mins.as necessary Magnesium sulphate (25 mg/kg i.v, max 2g)Magnesium sulphate (25 mg/kg i.v, max 2g) Mechanical ventilationMechanical ventilation

Indications of mechanical Indications of mechanical venti lation in acute severe venti lation in acute severe asthmaasthma

ComaComa Respiratory arrestRespiratory arrest Deterioration of ABG despite optimal Deterioration of ABG despite optimal

therapytherapy PaO2 < 8 kPa and fallingPaO2 < 8 kPa and falling PaCO2 > 6 kPa and risingPaCO2 > 6 kPa and rising Ph low and fallingPh low and falling Exhaustion , confusion and drowsinessExhaustion , confusion and drowsiness

Monitoring of treatment -Monitoring of treatment - PEF recording made every 15-30 mins. PEF recording made every 15-30 mins.

to assess early response to assess early response In hospital setting - PEF charted 4-6 In hospital setting - PEF charted 4-6

hrly. before and after inhaled hrly. before and after inhaled bronchodilator throughout period of bronchodilator throughout period of hospital stayhospital stay

Repeat measurement of ABG Repeat measurement of ABG Continuous monitoring of OContinuous monitoring of O 22 saturation saturation

by pulse oximetryby pulse oximetry