2. WHO DEFINITION OF ASTHMA
"A chronic inflammatory disorder of the airways in
which many cells play a role, in particular mast
cells, eosinophils, and T lymphocytes. In
susceptible individuals this inflammation causes
recurrent episodes of wheezing, breathlessness,
chest tightness, and cough particularly at night
and/or in the early morning. These symptoms are
usually associated with widespread but variable
airflow limitation that is at least partly reversible
either spontaneously or with treatment. The
inflammation also causes an associated increase in
airway responsiveness to a variety of stimuli."
6. A peak flow meter
at home
the convenience and ease of use
measure the PEFR (peak expiratory
flow rate) by taking a deep breath
and then blowing into a tube on the
meter as hard and as fast as patient
can.
every day, sometimes several times
a day, and keep track of these rates
over time --are compared with
charts that list normal values for sex,
race, and height.
A spirometer
in a doctor's office
gives a more accurate measure of lung
function
diagnose asthma, classify its severity, and
help decide what is the best way to treat
asthma
done periodically
The total volume patient exhale is called
"forced vital capacity," or FVC
measures the volume of air patient exhale
in the first second. (This is referred to as
"forced expiratory volume in one second,"
or FEV1.)
Patient will be given a bronchodilator and
•You would not consider managing hypertension without a sphygmomanometer,
or diabetes without a glucometer –
• accurate and objective assessmentand management of asthma is not possible
without a spirometer or peak flow meter
7. The Peakflow or Peak Expiratory Flow or PEF
indicates how severe the asthma crisis is:
PEF values to keep in mind :
Normal for a man : 600 l/min
Normal for a woman : 450 l/min
Values depending on severity (in % of normal value):
Acute asthma Serious crisis Light/moderate
crisis
PEF impossible
or 30%
( 180 l/min)
PEF = 30 to 50%
(180 to 300 l/min)
PEF 50%
( 300 l/min)
8. MANAGING ASTHMA:
PEAK FLOW CHART
People with
moderate or
severe asthma
should take
readings:
Every morning
Every evening
After an
exacerbation
Before inhaling
certain
medications
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For
Asthma Created and funded by NIH/NHLBI
9. Sputum esinophilia.
Chest X-Ray (For DD , complications).
Skin tests (For Allergen Identification) .
Bronchoprovocation (For Suspected Cases).
Several types of bronchoprovocation testing are available to
assess airway responsiveness in specific patient situations,
including pharmacologic challenge, exercise challenge,
eucapnic voluntary hyperpnea, food additive challenge, and
antigen challenge.
INVESTIGATIONS
11. 27-Dec-15
11
Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms Nocturnal
Symptoms
FEV1 or PEF
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
Continuous
Limited physical
activity
Daily
Attacks affect activity
> 1 time a week
but < 1 time a day
< 1 time a week
Asymptomatic
and normal PEF
between attacks
Frequent
> 1 time week
> 2 times a month
2 times a month
60% predicted
Variability > 30%
60 - 80% predicted
Variability > 30%
80% predicted
Variability 20 - 30%
80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.
12. GOALS OF THERAPY
Minimal or no chronic symptoms day or night
Minimal or no exacerbations
No limitations on activities; no school/work missed
Maintain (near) normal pulmonary function
Minimal use of short-acting inhaled beta 2 agonist
Minimal or no adverse effects from medications
13. STEPWISE APPROACH
Review treatment every 1 to 6 months, and
gradually step down treatment
If asthma controlled not maintained, then a step up
in treatment may be warranted
14. REASONS FOR POOR ASTHMA CONTROL
Inhaler Technique
Compliance
Environment
Also assess for an alternative diagnosis
“All that wheezes is not asthma, and not all asthma
wheezes”
15. FACTORS AFFECTING COMPLIANCE
Support of health care professional and family
Route of drug administration (inhaled vs. oral)
Complexity of drug regimens
Side effects of medications
$$ Cost $$
16. • Pregnancy does not increase the frequency or
severity of asthma.
• Progesterone reduces spasm and relaxes smooth
muscle. Bronchi are widened and mucus regulated.
(Progesterone receptors are widely present in
submucosal tissue.)
• Studies suggest that 11-18% of pregnant women
with asthma will have at least one emergency
department visit for acute asthma and of these
62% will require hospitalization1.
• One third of the asthmatic women feel better
during pregnancy.
_______________________________________________________
1. Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, et al.
Perinatal outcomes in the pregnancies of asthmatic women: a prospective
controlled analysis. Am J Respir Crit Care Med 1995;151(4):1170-4
18. Lung Volumes and Capacities
Tidal volumes increases gradually(35-50%).
Total lung capacity is reduced (4-5%) by the elevation of
the diaphragm.
FRC (Functional Residual Capacity) and RV (Residual
Volume) decrease by about 20%.
Effects of Labour on the Pulmonary System
There is a further decrease in FRC during the early
phase of each uterine contraction
20. 27-Dec-15
20
EFFECT OF ASTHMA ON PREGNANCY
SPECIALLY IF UNTREATED WELL
MATERNAL
ED visits
hospitalizations
hyperemesis
vaginal hemorrhage
& accidental
haemorrhage due to
severe coughing
CS
respiratory failure
PIH
death
FETAL
Oligohydroamnios
LBW
premature delivery
fetal demise
Meconium staining
NEONATAL
neonatal hypoxemia
low newborn
assessment scores
perinatal mortality
21. DRUG THERAPY IN PREGNANCY
In general, the drugs used to treat asthma are safe in
pregnancy.
Quick relief medications
Long-term control medications
23. 27-Dec-1523
LONG TERM ‘CONTROLLER ’ MEDICATIONS
Corticosteroids
Leukotriene modifiers
Zafirlukast, Montelukast,Zileuton
Mast cell stabilisers
Nedocromil/Cromolyn
Long acting β2-agonists
Salmeterol, Formoterol, Bambuterol
Methylxanthines
Theophylline
Anticholinergics
Ipratropium bromide
Bronchodilators
MOA:
Prevent or
reverse
inflammation
24. 27-Dec-1524
QUICK RELIEF AGONISTS
MOA:
1. receptors G protein cAMP Bronchodilatation
2. mucociliary transport
3. release of mediators
Short acting (30-90 min.) (epinephrine, isoproterenol,
isoetharine)
Adv: Immediate action
Disadv: Only by inhalation or parenteral
25. 27-Dec-1525
Long acting(4-6 h): Selective 2-agonists terbutaline,
fenoterol, Salbutamol(albuterol)
Adv: Highly specific, No cardiac side effect except high
doses
Can be given by all routes
Disadv: Tremors
Salbutamol: 2-4 mg oral, 0.5 mg im/s.c, 100-200 g/puff
Preferred route inhalation, equivalent to iv in severe asthma
Terbutaline: 0.25 mg sc or inhalation, 5 mg oral
26. 27-Dec-1526
Ultra long(9 to 12 h): Salmeterol & formoterol
For nocturnal and exercise-induced asthma
Adv: Anti-inflammatory activities
Disadv: Not recommended for acute episodes
Salmeterol: 25 g/puff MDI, 2 puffs BD.
‘SEROFLO’ ROTACAPS (Salm + fluticasone), MDI
27. 27-Dec-1527
METHYLXANTHINES
Medium potency bronchodilators with ?
anti-inflammatory properties.
2nd line drug
Rarely used in acute condition
Adv: “Controller class”,
Single evening dose nocturnal
symptoms
Theophylline: 100-300 mg TDS
Aminophylline: Slow iv 250-500 mg
28. 27-Dec-1528
GLUCOCORTICOIDS
Ind: Acute illness with failure of optimal
bronchodilators
Chronic disease with frequent
recurrence & severity
Inhaled for long term control of asthma
Adv:
Most potent
Max. antiinflammatory
29. 27-Dec-1529
MP
Dose: 120-180 mg iv QD
7-60 mg daily OD am as needed for control
Prednisolone
Dose: 60 mg QDS. Taper ½ q 5th day after 10-12 days of
acute episode
S/E:
Long delay to peak action
Interrrupted growth, Gastric ulcer.
30. 27-Dec-1530
Inhaled steroids
Persistent symptoms & control inflammation
Facilitate the long-term prevention
need for oral steroids
Minimize acute occurrences & hospitalizations
Beclomethasone: 100,200,250 g
Budesonide: 200, 400 g BD- QID
Fluticasone: 25,50,125 g inhalation, rotacaps
100-250 g BD
Dose needs to be individually titrated
31. 27-Dec-1531
LEUKOTRIENE RECEPTOR ANTAGONISTS
Zafirlukast, Montelukast,
MOA:
Inhibit or antagonise competitively against LTD4 receptor
Modest bronchodilator to asthma
exercise induced & nocturnal symptoms
Montelukast: 10 mg OD
Zafirlukast: 20 mg BD
32. 27-Dec-1532
Disadv:
Hep. Enz.
Interact with the drugs metabolised by liver
+ve responders < 50 %
No response in 1 month STOP
33. 27-Dec-1533
MAST CELL STABILISERS
Nedocromil Na, Cromolyn Na
MOA:
Inhibit degranulation of mast cells
Reduce symptoms
Lower airway reactivity
Ind:
Atopic patients with seasonal disease
Exercise or cold induced asthma
Adv:
Can be given 15-20 minutes b/f contact as it can abolish
late reaction
Cromolyn: 1mg/puff, 2 puffs QDS
Nedocromil: 4 mg or 2 puffs BD
34. Steroid tablets
Use as normal when indicated. Steroid tablets should
never be withheld because of pregnancy.
First trimester exposure to oral steroids may slightly
increase the risk of cleft lip/palate2.
The benefits of treatment outweigh the risks.
_______________________________
____
2.Czeizel AE, Rockenbauer M. Population-based case control study of
teratogenic potential of corticosteroids. Teratology 1997;56(5):335-
40.
35. Treatment Protocol
DIAGNOSIS BASED ON SYMPTOMS & OBJECTIVE ASSESSMENT
ASSESS SEVERITY
MILD MODERATE SEVERE
ENVIRONMENTAL CONTROL AND EDUCATION
ADDITIONAL THERAPY
INHALED CORTICOSTEROIDS
INHALED SHORT-ACTING BETA2-AGONIST PRN
42. MANAGEMENT OF ACUTE ASTHMA IN
PREGNANCY
Give drug therapy for acute asthma as for the non-
pregnant patient.
High flow oxygen.
Acute severe asthma in pregnancy is an
emergency and should be treated vigorously in
hospital.
Continuous fetal monitoring
43. • For induction of labor, oxytocin is preferred over
various prostaglandin (PG) preparations.
• Intravaginal or intracervical PGE2 gel has not been
reported to cause bronchospasm but IV can cause
• Lumbar epidural analgesia reduces oxygen
consumption and minute ventilation during the first and
the second stages of labor and may considerably
advantageous to patients with asthma
• If general anesthesia is needed:
- Pretreatment with atropine may provide a
bronchodilating effect.
-Ketamine is the agent of choice for anesthesia
induction
• Use of non steroidal may be dangerous
44. • Whenever possible if RA can do, it is preferred to general
• Avoid GA as possible in patients at risk of aspiration of gastric
contents:
Emergency surgery in non fasting patient
Gastroesophageal reflux
Marked obesity
Bowel obstruction
Gastroparesis (trauma or diabetes)
Pregnancy, or other factors increasing intragastric
pressure
45.
46. DURING DELIVERY
Only about 1 in 10 women with asthma have symptoms during
delivery.
The increase in plasma epinephrine that occurs during labor
and delivery may contribute to the absence of asthma
symptoms during this critical time period
47. MANAGEMENT DURING LABOUR
Acute asthma is rare in labour.
Continue usual asthma medications.
Avoid general anesthesia if possible.
Avoid prostaglandin F2α ( Dinoprost for induction ) and
ergometrine (Synto)
Women receiving steroid tablets at a dose exceeding
prednisolone 7.5mg per day for more than 2 weeks prior
to delivery should receive parenteral hydrocortisone
100mg 6-8 hourly during labour.
48. ADVICE TO MOTHER
Importance and safety of continuing their asthma
medications during pregnancy to ensure good asthma
control.
The harm of severe or chronically under-treated asthma
outweighs any small risk from the medications.
49. SELF-MANAGEMENT OF ASTHMA OUTPATIENT
MANAGEMENT OF ASTHMA
Teach the patient self-management (Level of Evidence=A;
The patient should have good knowledge of self-management.
The components of successful self-management are acceptance of
asthma and its treatment effective and compliant use of drugs
a PEF meter and follow-up sheets at home
written instructions for different problems
As a part of controlled self-management the patient can be given
a PEF follow-up sheet with individually determined alarm limits and the
following instructions (Level of Evidence=B;
If the morning PEF values are 85% of the patient´s earlier optimal value,
the dose of the inhaled corticosteroid should be doubled for two weeks.
If the morning PEF values are below 50 - 70% of the optimal value the
patient can start a course of prednisolon 40 mg daily for one week and
contact the doctor by telephone.
50. REFERRENCE
BRITISH GUIDELINE ON THE MANAGEMENT OF ASTHMA
(UPDATED 2009)
UptoDate 2011
Asthma in Pregnancy by Timothy Hoskins, M.D.October 5, 2005