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

2. 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

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

5. The Respiratory System

6. 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

7. 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

10. Risk Factors Family History Parental tobacco use
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)

11. 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)

12. 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

13. 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

14. 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

15. Asthma Triggers

16. Asthma Triggers

17. Asthma Triggers

19. 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

20. 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

21. 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.

22. 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

23. 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

25. 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.

26. 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.

27. 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)

28. 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

29. 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

30. 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.

31. Cough Variant Asthma Chronic cough – Occur any age group PFTs –normal
Cough > 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

32. Asthma Evaluation Differential 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

33. Asthma Evaluation Differential Diagnosis
Small Airway obstruction
Viral Bronchiolitis
Bronchiolitis obliterans
Cystic Fibrosis
Bronchopulmonary dysplasia
Heart disease
Other Causes
Psychogenic cough
GERD
ACE inhibitors

34. Asthma Evaluation History
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

35. Asthma Evaluation History
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

36. Asthma Evaluation History
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

37. Asthma Evaluation Signs: Respiratory distress
Tachypnea
Dyspnea
Anxiety
Accessory Muscle Use
Intercostal muscle use
Sternocleidomastoid use
Scalenes Muscle use
Cyanosis in severe cases (lips)
Tachycardia

38. Asthma Evaluation Radiology: 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: 34%
Status Asthmaticus or no acute asthma improvement
Excludes other diagnoses
CHF
Pneumonia
Excludes complications
Pneumothorax
Pneumomediastinum

39. Asthma Evaluation Labs
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

40. Asthma Evaluation Other Diagnostic Tests
PFT’s – Pulmonary Function Testing
Spirometry
Methacholine Challenge

41. 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

42. 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

43. 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

44. 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

45. PFT- Spirometry Definitions
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
FEF forced expiratory flow - the average forced expiratory flow during the mid ( %) portion of the FVC
PEF - peak expiratory flow rate - the peak flow rate during expiration

46. PFT- Spirometry
In general, a > 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

48. Mild Obstruction Flow Volume
                        
Normal Flow Volume Loop
                           
                                                      
                                         

49. 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

50. 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)

54. Status Asthmaticus Emergency Management of Asthma Exacerbation

55. Indications of severe attack
Breathless at rest
Hunched forward
Talking in words rather than sentences
Agitated
Peak flow rate < than 60% of normal

56. 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.

57. 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

58. 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 <50% of predicted (Severe)
Systemic Corticosteroid (PO or IV Indications)
Severe episode (FEV1 or PEF <50% predicted)
No immediate response
Oral corticosteroid recently taken by patient
Oxygen indications
Adults: O2 saturation <91%
Children: 02 saturation <96%

59. 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

60. 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

61. 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
Won’t directly trigger asthma, can produce persistent cough causing increased wheezing
Beta blockers
NSAIDs
can trigger severe and even fatal asthma attacks

62. Asthma Management Goals

67. 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

68. Questions?