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BRONCHIAL ASTHMA ASTHMA IS DEFINED AS REVERSIBLE OBSTRUCTION OF LARGE AND SMALL AIRWAYS DUE TO HYPERRESPONSIVENESS TO VARIOUS IMMUNOLOGIC AND NONIMMUNOLOGIC.

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Presentation on theme: "BRONCHIAL ASTHMA ASTHMA IS DEFINED AS REVERSIBLE OBSTRUCTION OF LARGE AND SMALL AIRWAYS DUE TO HYPERRESPONSIVENESS TO VARIOUS IMMUNOLOGIC AND NONIMMUNOLOGIC."— Presentation transcript:

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2 BRONCHIAL ASTHMA ASTHMA IS DEFINED AS REVERSIBLE OBSTRUCTION OF LARGE AND SMALL AIRWAYS DUE TO HYPERRESPONSIVENESS TO VARIOUS IMMUNOLOGIC AND NONIMMUNOLOGIC STIMULI “ASTHMA IS AN EOZINOPHYLIC INFLAMMATION OF THE AIRWAYS” PREVALANCE 7-12%

3 CLASSIFICATION A) ALLERGIC OR EXTRINSIC ASTHMA POLLENS FOODS DUST MITESIgE MEDIATED ANIMAL DANDERS RSV

4 B) INTRINSIC OR NONALLERGIC ASTHMA TEMPERATURE CHANGES COLD AIR ODOR IRRITANS MENSES SMOKE VIRUS C) EXERCISE INDUCED ASTHMA D) ASPIRIN INDUCED ASTHMA

5 RISK FACTORS FOR CHILDHOOD ASTHMA FAMILIAL AND GENETIC FACTORS ATOPY ENVIRONMENTAL FACTORS VIRAL RESPIRATORY TRACT INFECTION BACTERIAL? AMBIENT AIR POLLUTION (NO2, SO2, O3) PASSIVE EXPOSURE TO CIGARETTE SMOKE PSYHOLOGIC FACTORS COLD AIR EXERCISE

6 RISK FACTORS FOR CHILDHOOD ASTHMA NASAL POLYPS ASPIRIN  REACT ALSO TO TARTARAZINE YELLOW URTICARIA (INHIBITS CYCLOOXYGENASE PATWAY) PRESERVATIVE (SULFIDES) LETTUCE FRESH SALAD DRIED FRUITS DRIED POTATOES WINE SOFT DRINKS

7 MECHANISM OF ASTHMA ALLERGIC MECHANISM (IgE MEDIATED) AUTONOMIC REGULATION  ADRENERGIC  ADRENERGIC ? CHOLINERGIC

8 İnhale allerjen  antijen sunan hücre Karşılıklı etkileşim THO → IL4 → TH 2 IL 4 IL 3 plasma hücresi IgE yapımı mast hücresinden Kanda IgE doku mast hücresi FcεR 1 bozofil (yüksek afiniteli) histamin önceden serotinin mevcut lenfosit eo FcεR 2 lokotrienler sonra trombosit (düşük afiniteli) prostoglandin yapılanlar Makrofaj - Bronş düz kas kasılmaları - Damar geçirgenliğinde artma - Mukus sekresonunda artma Erken Faz Reaksiyonu Tip I Reaksiyonu

9 MEDIATORS WITH ACTIONS THAT CAUSE AIRWAY OBSTRUCTION BRONCHOCONSTRICTION HISTAMINE BRADYKININ LEUKOTRIENES C.D.E PGD2, PGF2  THROMBOXANE A2 AND B2 INCREASED CAPİLLARY PERMEABILITY HISTAMINE BRADYKININ LEUKOTRIENES C.D.E PGE SECRETION OF MUCUS HISTAMINE LEUKOTRIENES C.D HETEs PGD2, PGF2 , PGI2, PGE

10 PATHOLOGY OF ASTHMA ALLERGIC AND NONSPESIFIC STIMULI (COLD AIR EXERCISE, ASA) ↓ SMOOTH MUSCLE SPASM AIRWAYS INFLAMMATION MUCOUS PLUGGING OF THE AIRWAYS CELLULAR INFILTRATION OF THE AIRWAYS CHEMICAL MEDIATORS AND NONSPESIFIC STIMULI ↓ BRONCHOCONSTRICTION, MUCOSAL EDEMA EXCESSIVE SECRETIONS ↓ AIRWAY OBSTRUCTION ↓ ↓ ↓ ATELECTASIS NON UNIFORMHYPERINFLATION VENTILATION ↓ ↓ MISMATCHING DECREASED OF VENTILATIONCOMPLIANCE AND PERFUSION ↓ ↓ ALVEOLARINCREASED DECRAESEDHYPOVENTI WORK OF BREATHING LATION ASIDOSIS PULMONARY VASOCONSTRICTION THE PATHOPHYSIOLOGY OF ASTHMA PCO2 PO2

11 CLINICAL FINDINGS RECURRENT EPISODES OF COUGH DYSPNEA WHEEZING - PAROXYSMAL COUGHING AND INDUCES VOMITING - SHORTNESS OF BREATH - A FEELING OF TIGHTNESS IN THE CHEST - POOR EXERCISE TOLERANCE - RECURRENT CHEST COLDS OR PNEUMONIA

12 DIAGNOSIS HISTORY ATOPY CLINICAL FINDINGS LABROTORY FINDINGS

13 PHYSICAL EXAMINATION PROLONGATION OF EXSPIRATION HIGH-PIYCHED MUSICAL WHEEZING LOUDER ON EXSPIRATION COARSE RHONCHI ELEVATION OF THE RIBS (INSPECTION) USE OF THE ACCESSORY MUSCLES PULSUS PARADOXICUS INDICATES PULSE RATE  SEVERE RESPIRATION RATE RISES TO OBSTRUCTION CYANOSIS

14 MILD INTERMITENT – PRESİSTENT ASTHMA CONSTITUES UP TO 75% OF THE CHILDHOOD ASTHMATIC POPULATION AND IS ASSOCIATED WITH EPISODIC OCCURING LESS THAN ONCE EVERY 4-6 WEEKS MINOR WHEEZING AFTER HEAVY EXERTION NO OBVIOUS SYMPTOMSBETWEEN OR FUNCTIONAL IMPAIRMENTEPISODES NORMAL LUNG FUNCTION BETWEEN EPISODES PROPHYLACTIC THERAPY IS USUALLY NOT REQUIRED

15 MODERATE ASTHMA FREQUENT EPISODIC ASTHMA CONSTITUES ABOUT 20% OF THE ASTHMA POPULATION AND IS ASSOCIATED WITH SOME WHAT MORE FREQUENT ATTACK AND WHEEZE ON MODERATE EXERCISE, BUT IS PREVENT BY PREDOSING WITH A B2 AGONIST. SYMPTOMS OCCUR LESS FREQUENTLY THAN ONCE A WEEK AND THERE IS NORMAL OR NEAR NORMAL LUNG FUNCTION BETWEEN EPISODES. PROPHYLACTIC TREATMENT IS USUALLY NECESSARY

16 SEVERE ASTHMA PERSISTENT ASTHMA AFFECTS ROUGHLY 5% CHILDREN WITH ASTHMA AND IS ASSOCIATED WITH FREQUENT ACUTE EPISODES, WHEEZING WITH MINOR EXERTION, AND INTERVAL SYMPTOMS REQUIRING B2 AGONIST DRUGS MORE THAN 3 TIMES A WEEK BECAUSE OF EITHER NIGHT WAKENING OR CHEST TIGHTNESS IN THE MORNING. THERE IS NEARLY ALWAYS EVIDENCE OF AIRFLOW LIMITATION BETWEEN EPISODES. PROPHYLACTIC TREATMENT IS MANDATORY.

17 LABORATORY TESTS BLOOD COUNT EOSINOPHILIS NASAL EOSINOPHIL COUNT  10% (+) IMMUNGLOBULINS (G. A. M) (G1. G2. G3. G4) IgE SKIN TESTS CHEST X-RAY PPD X-RAY FILMS OF PARANASAL SINUSIS  1 ANTITRYPSIN MEASUREMENT OF SWEAT ELECTROLYTES PULMONARY FUNCTION TEST PO2 PCO2 BICARBONATE LEVELS

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19 PULMONARY FUNCTION TEST IN ASTHMA TOTAL LUNG CAPACITY FUNCTIONAL RESUDIAL CAPACITY RESUDIAL VOLUME ARE INCREASED VITAL CAPACITY  FORCED VITAL CAPACITY (FVC)  FORCED EXPIRATORY VOLUME IN 1 sec (FEV1)  PEAK FLOW RATE (PFR)  Mild %  80 Modere %60 – 80 Severe  60

20 PULMONARY FUNCTION TEST IF THE FEV1 VALUE INCREASES BY 15% AFTER THE ADMINISTRATION OF AEOROLIZE BRONCHODILATATOR ASTHMA IS DIAGNOSED. IN EIA FEV1 VALUE DECREASEMENTS BY 15% AFTER EXERCISES IS A REASON FOR DIAGNOSIS OF EIA ASTHMA

21 DIFFERENTIAL DIAGNOSIS INFANTS AND YOUNG CHILDREN BRONCHIOLITIS FOREIGN BODY CROUP EPIGLOTTITIS CYSTIC FIBROSIS

22 DIFFERENTIAL DIAGNOSIS IMMOTILE CILIA SYNDROME HABIT COUGH BRONCHOPULMONARY DYSPLASIA TRACHEOMALACIA TRACHOESOPHAGEAL FISTULA, ANOMALIES OF AORTIC ARCH GASTROESOPHAGEAL REFLUX

23 OLDER CHILDREN AND YOUNG ADULTS TBC HABIT COUGH VOCAL CORD DYSFUNCTION HYPERVENTILATION  1 ANTITRYPSIN DEFICIENCY CYSTIC FIBROSIS IMMOTILE CILIA SYNDROME CARCINOID SYNDROME BRONCHIECTASIS

24 COMPLICATIONS I INFECTION BRONCHITIS PNEUMONITIS SINUSITIS O.MEDIA BRONCHIECTASIS ATELECTASIS MEDIASTINAL AN SUBCUTANEOUS EMPHYSEMA

25 COMPLICATIONS II PNEUMOTHORAX COUGH SYNCOPE GROWTH COMPLICATIONS A) INHIBITION OF LINEAR GROWTH AND BONE MATURATION B) THORACIC DEFORMITIES COR PULMONALE EMPHYSEMA STATUS ASTHMATICUS POLIOMYELITIS LIKE ILLNESS

26 MEDICAL TREATMENT

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32 BRONCHODILATORS DRUGS BETA-2 ADRENERGIC AGONISTS BETA- AGONIST PRODUCE BRONCHODILATATION BY DIRECTLY STIMULATING BETA-2 RECEPTORS IN AIRWAY SMOOTH MUSCLE, WHICH LEADS TO RELAXATION

33  2 agonist Etken madde İlaç adıVeriliş yolu Doz Short actingTerbutalineBricanlyMDI200 mcq BricanlySusp SalbutomalVentolinMDI100 mcq Ventolinnebul2-5 mg Ventolinsusp Long actingSalmoteralSereventMDI25-50 mcq AstmerolMDI25-50 mcq FormoteralForodilMDI12 mcq AntıcholınergıcIpratropium bromide AtroventMDI20 mcq

34 ANTICHOLINERGIC:ATROVENT NEBUL 6-12 YEAR0,25 mgEVERY 6 h 12 YEAR  0,5 mgEVERY 6 h SIDE EFFECT: MUSCLE TREMOR, TACHYCARDIA PALPILATION, HYPOKALEMIA

35 ANTI-INFLAMMATORY DRUGS 1- CORTICOSTEROID: CORTICOSTEROIDS HAS ANTI-INFLAMMATORY EFFECTS CORTICOSTEROIDS SUPRESSING TRANSCRIPTION OF INFLAMMATORY GENES HAVE INHIBITORY EFFECTS ON MANY INFLAMMATORY AND STRUCTURAL CELLS, CYTOKIN ES (IL1, IL5, IL13, TNF, CMCSF)

36 ANTI-INFLAMMATORY DRUGS IT IS IMPORTANT TO RECOGNISE THAT STEROIDS SUPRESS INFLAMMATION IN THE AIRWAYS BUT DO NOT CURE THE UNDERLYING DISEASE

37 Etken maddeIlaç adıVeriliş yoluDoz IVHydrocortisone2-4 mg/kgEvery 6 hr ORALPrednisone1-2 mg/kgmax mg/day prednisolone INHALEDBeclamethasoneBeclaforteMDI250 mcq dipropionateBecotideMDI50 mcq BudesonidPulmicortturbahaler mcq PulmicortMDI mcq FluticasoneFlixotide mcq propinateFlixotidediscus100 mcq

38 SIDE EFFECT: DYSPHONIA, ORAPHARYNGEAL CANDIDIASIS, COUGH, ADRENAL SUPRESSION, GROWTH SUPRESSION, CATARACTS, GLOUCOME, OSTEOPROSIS

39 2- METHYLXANTHINES THEOPHYLLINE, ALTHOUGH INEXPENSIVE IS A DRUG THAT IS LESS EFFECTIVE AS BRONCHODILATATORS THAN  2 AGONIST AND THAT HAS LESS ANTI INFLAMATORY EFFECT THAN INHALED STEROIDS. HOWEVER IN PATIENTS WITH SEVERE ASTHMA THEOPHYLLINE STILL REMAINS A VERY USEFUL DRUG “THERE IS EVIDENCE THAT THEOPHYLLINE HAS AN ANTI-INFLAMATORY OR IMMUNOMODULATORY EFFECT”

40 THE INHIBITORY EFFECT OF THEOPHYLLINE ON PHOSPHODIESTERASES MAY RESULT IN BRONCHODILATATION AND INHIBITION ON INFLAMATORY CELLS THERAPEUTIC RANGE IS 10 TO 20 mg/L OPTIMAL DOSES 10 mg/L THERE IS NOT ORAL SHORT ACTING THEOPHYLLINE IN TURKEY I.V AMINOCARDOL 2-4 mg/kg/dose

41 Theo-Dur mg Talotren mg Theo-Kap mg SLOW-RELEASE PREPARATIONS SIDE EFFECT: NAUSEA, VOMITING, GASTRIC DISCOMFORT, HEADACHES CARDIAC ARRYHYTMIAS, EPILEPTIC SEIZURES

42 2- CROMOLYN SODIUM IS A MAST CELL STABILIZER POTENTLY INHIBIT BRONCHOCONSTRICTION INDUCED BY SULFURDIOXIDE, METABISULFITE AND BRADYKININ WHICH ARE BELIEVED TO ACT THROUGH ACTIVATION OF SENSORY NERVES IN THE AIRWAY HAVE VARIABLE INHIBITORY ACTIONS ON OTHER INFLAMMATORY CELLS THAT MAY PARTICIPATE IN ALLERGIC INFLAMMATION INCLUDING MACRAPHAGES AND EOSINOPHILIS

43 2- CROMOLYN SODIUM BLOCKING EARLY BUT ALSO THE LATE RESPONSE PROTECTS INDIRECT BRONCHOCONSTRICTOR STIMULI SUCH AS EXERCISES AND FOG LONG-TERM TREATMENT WITH CROMONES REDUCES AIRWAY HYPERRESPONSIVENESS CROMOLYN IS A PROPHYLACTIC DRUG OF FIRST CHOISE IN CHILDREN BECAUSE IT HAS ALMOST NO SIDE EFFECTS INTAL 5 mg MDI 4x1

44 SIDE EFFECTS: CROMOLYN IS ONE OF THE SAFEST DRUGS AVAILABLE AND SIDE EFFECTS ARE EXTREMELY RARE. THROAT IRRITATION, COUGHING

45 3- ANTI- LEUCOTRIENES THESE DRUGS INHIBITS BRONCHOCONSTRICTION INDUCED BY ALLERGEN, EXERCISE, COLD AIR AND MUCUS SECRETIONS AND MAY ALSO AN EOSINOPHILIC INFLAMMATION IN THE AIRWAYS. ALSO IT HAS BENEFOCAL EFFECT IN ALLERGIC RHINITIS AND EIA. ONE OF THE MAJOR ADVANTAGES OF ANTI- LEUCOTRIENES IS THAT THEY ARE ACTIVE IN TABLET FORM. THIS MAY INCREASE THE COMPLIANCE WITH CHRONIC THERAPY AND IT WILL MAKE TREATMENT OF CHILDREN EASIER

46 5 YEAR↓ 4 mg ONCE A DAY MONTELUKAST5-14 YEAR 5 mg “ “ (SINGULAIR)14 YEAR  10 mg “ “ ZAFIRLUKAST12 YEAR  2x1 (ACCOLATE)

47 SIDE EFFECT: MONTELUKAST WELL TOLERATED IN CHILDREN WITH NO SIGNIFICANT ADVERSE EFFECTS. HIGH DOSES OF ZAFIRLUKAST MAY BE ASSOCIATED WITH ABNORMAL LIVER FUNCTION

48 4- KETOTIFEN KETOTIFEN IS A PROPHYLACTIC ANTIHISTAMINIC DRUG. IT IS CLAIMED THAT KETOTIFEN HAS DISEASE MODIFYING EFFECTS IF STARTED EARLY IN CHILDHOOD ASTHMA AND MAY EVEN PREVENT THE DEVELOPMENT OF ASTHMA IN ATOPIC CHILDREN ZADITENSUSP5 ml=1 mg2x1 TABLET1 mg 2x1

49 NEDOCROMIL SODIUM: NEDOCROMIL SODIUM HAS ANTI INFLAMATORY EFFECTS. IT IS EFFECTIVE IN EIA TILADE4 mg 2-4x4 puff 6 YEAR  SIDE EFFECTS: SAME AS CROMOLYN SODIUM

50 IMMUNOTHERAPY HYPOSENSITIZATION: INVOLVES THE INJECTION OF AQUEOUS EXTRACTS OF ALLERGENS GIVEN AT REGULAR INTERVALS IT SHOULD NOT BE USED UNDER 5 YEARS IT IS MOST EFFECTIVE IN ALLERGIC RHINOCONJUNCTIVIS WITH OR WITHOUT ASTHMA

51 IMMUNOTHERAPY IT SEEMS TO BE MORE EFFECTIVE IN CHILDREN THAN IN ADULTS IT IS MORE EFFECTIVE WHEN EMPLOYING HIGH DOSE SINGLE-ALLERGEN THERAPY IT MUST BE APPLILED BY A SPECIALIST

52 Table 1 NAEPP elassification of disease severity* Disease serveritySymptoms/day Symptoms/night Peak flow or FEV 1 Peak flow variability Mild İntermittent< 2 days/week < 2 nights/month >80% <20% Mild persistent> 2 week but 2 nights/month >80% 20-30% Modere persistentDaily >1 night/week >60% - <80% >30% Severe persistentContinual Frequent <60% >30%

53 Table 2 Stepwise approach for managing infants and young children (<5 years Severity classDaily medications Step 4 Severe persistent Preferred treatment: high-dose ICS + LABA and, if needed: corticosteroid tablets or syrup long-term Step 3 Moderate persistent Preferred treatment: low-dose ICS + LABA or medium-dose ICS Alternative treatment: low-dose ICS + LTRA or theophylline If needed: medium-dose ICS + LABA Alternative treatment: medium-dose ICS + LTRA or theophylline Step 2 Mild persistent Preferred treatment: low-dose ICS Alternative treatment: cromolyn or LTRA Step 1 Mild intermittent No daily medication needed

54 Table 3 Stepwise approach for adults and children (>5 years) Severity classDaily medications Step 4 Severe persistent Preferred treatment: high-dose ICS + LABA and, if needed, corticosteroid tablets or syrup long-term Step 3 Moderate persistent Preferred treatment: low-to-medium dose ICS + LABA Alternative treatment: increase ICS dose within medium- dose range OR low-to-medium dose ICS + LTRA OR theophylline If needed: increase medium-dose ICS + LABA Alternative treatment: increase medium-dose ICS + LTRA or theophylline Step 2 Mild persistent Preferred treatment: low-dose ICS Alternative treatment: cromolyn, LTRA, nedocromil or theophylline SR (serum concertration of μ/mL) or LTRA Step 1 Mild intermittent No daily medication needed

55 TREATMENT OF ACUTE EPISODES OF ASTHMA MILDIS ASSOCIATED WITH COUGH AND AUDIBLE WHEEZING WITHOUT ANY FROM OF DISTRESS, CYANOSIS, INCREASED RESPIRATORY RATE OR IMPAIRMENT OF ACTIVITY, THEY CAN SPEAK IN NORMAL SENTENCES BETWEEN BREATHS. PEF OR FEV, ABOVE 75% OF PREDICTED VALUES MODERATEIS ASSOCIATED AUDIBLE WHEEZE, USE OF ACCESSORY MUSCLES, A SLIGHT INCREASE IN RESPIRATORY RATE, INABILITY TO WALK, THEY CAN SPEAK MORE THAN THREE OR FIVE WORDS BETWEEN BREATHS SEVEREIS ASSOCIATED WITH CYANOSIS SEVERE DISTRESS, LOWER RIB RETRACTION, ONLY ONE TO THREE WORDS OF SPEESH WILL BE POSSIBLE BETWEEN BREATH AND THE PATIENT WILL BE CHAIR OR BED BOUND

56 TREATMENT OF ACUTE EPISODES OF ASTHMA INHALED  2 AGONIST MDI (with or without a spacer) MILD4-6 hFOR24-36 h IF THERE IS RAPIDIF THERE IS NO IMPROVEMENT ADDED IMPROVEMENTIPRATROPIUM BROMIDE (by nebulizer) SEND TO HOMEOR HIGHER DOSES OF  2 AGONIST IF THERE IS INCOMPLETE RESPONSE OR RELAPS OF SYMPTOMS WITHIN 4 h MODERE ADDED ORAL CORTICOSTEROID (1-2 mg) IF THERE IS NO IMPROVEMENT AFTER 3 DOSES OF  2 AGONIST HOSPITALIZED NEBULIZED  2 AGONIST + OXYGEN SEVERE I.V HYDROCORTIZONE (4 mg/kg) EVERY 4-6 h IF THERE IS NOT IMPROVEMENT ADMISSION TO INTENSIVE CARE ADDED I.V AMINOPHYLLINE IF THERE IS NOT IMPRAVEMENT MECHANICAL VENTILATION


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