Asthma, breathing difficulty, pregnancy, shortness of breath, asthma medications, pregnancy, spirometry,

1. By La Lura White MD
Maternal Fetal Medicine
*

2. *
*Asthma:
* Chronic disease.
*Increased airway
responsiveness.
*Can occur spontaneously
or in response to various
stimuli.
* Physical exertion,
allergens, medications,
infection, emotions and
stress.

3. *
* In response to contact with a
triggering agents:
* Mast cells of the immune
system, which are found in loose
connective tissue release
vasoactive chemical mediators:
*Histamine
*Bradykinin
*Leukotrienes
*Cytokines
* Prostaglands

4. *
* Mast cells cause
neutrophils, lymphocytes
and eosinophils to
infiltrate the cells of the
bronchial lining.
* Cause
bronchoconstriction,
vascular congestion and
increases in capillary and
mucosal edema.
* Impaired mucociliary
action and increased
mucus production and
airway resistance.
*Airway obstruction that
is partially or completely
reversible.
*Development of
symptoms.

5. *
*Symptoms:
* Wheezing
*SOB
*Cough
*Chest tightness
*Difficulty breathing

6. *
*Diagnosis:
*History of symptoms.
* Spirometry :evaluation:
measures airflow
*Records the amount and
the rate of air that you
breathe in and out over a
period of time.

7. *
*Volume-time curve:
showing volume (liters)
along the Y-axis and
time (seconds) along
the X-axis
*FEV1 is the volume of
air that can forcibly be
blown out in one
second, after full
inspiration

8. *
*Dx:
*Symptoms
*Improvement in FEV1 after administration
of a short-acting inhaled B2-agonist.

9. *
*Asthma complicates 4–8% of
pregnancies.
*Prevalence of and morbidity from
asthma are increasing, although
asthma mortality rates have
decreased .
* Asthma symptoms peak in the
late second or early third
trimester. (29-36 weeks).
*Less severe during the last month
of pregnancy.

10. *
*1/3 aggravate
*1/3 improve (gradual improvement throughout
pregnancy)
*1/3 does not change
*Most return to their prepregnancy baseline within 3
months postpartum
*Most severe disease most likely to worsen during
pregnancy
*The severity of symptoms in first pregnancy is similar
in subsequent pregnancies.

11. *
* THE EFFECTS OF PREGNANCY ON ASTHMA
* Asthma has been associated with considerable maternal
morbidity.
* In a large prospective study:
* Mild asthma had an exacerbation rate of 12.6% and
hospitalization rate of 2.3%.
* Moderate asthma had an exacerbation rate of 25.7% and
hospitalization rate of 6.8%.
* Severe asthmatics had exacerbation of 51.9% and
hospitalization rate 26.9%.
* One of the most important conclusions to be made from
this study is that pregnant asthmatic patients, even with
mild or well-controlled disease, need to be monitored .

12. *
*Well-controlled, asthma can be associated with
excellent maternal and perinatal pregnancy outcomes.
*Severe and poorly controlled asthma: (FEV1 < 80%)
* Increased prematurity
*Increased cesarean delivery rate
*Preeclampsia
*Growth restriction (SGA)
*Increased maternal morbidity/ mortality
*Hypertension
*Existing studies on the effects of asthma on pregnancy
*outcomes have had inconsistent results with regard to
*maternal and perinatal outcomes

13. *
*Risk Factors
*Younger
*Unmarried
*Lower socioeconomic status
*Ethinic: Hispanic, Latino or African-American
*Obesity

14. *
*National Asthma Education and Prevention
Program (NAEPP)categorize asthma:
*Mild intermittent
*Mild persistent
*Moderate persistent
*Severe asthma

15. *
*Mild Intermittent Asthma
*Symptoms twice per week or less.
*Nocturnal symptoms twice per month or
less.
*PEFR or FEV1 80% predicted or more
*Variability less than 20%

16. *
*Mild Persistent Asthma
*Symptoms more than twice per week but not
daily.
*Nocturnal symptoms more than twice per
month.
*PEFR or FEV1 80% predicted or more
*Variability 20–30%

17. *
*Moderate Persistent Asthma
*Daily symptoms
*Nocturnal symptoms more than once per week
*PEFR or FEV1 more than 60% to less than 80%
predicted
*Variability more than 30%
*Regular medications necessary to control symptoms

18. *
*Severe Asthma
*Continuous symptoms and frequent exacerbations.
*Frequent nocturnal symptoms.
*PEFR or FEV1 60% predicted or less.
*Variability more than 30%.
*Regular oral corticosteroids necessary to control
symptoms.

19. *
*Management Goal
*Treat airway inflammation.
* Decrease airway responsiveness.
* Prevent asthma symptoms and exacerbations.
*Maintain adequate oxygenation to the fetus by
preventing hypoxic episodes in the mother.

20. *
*Optimal management:
*Avoiding or controlling asthma triggers
(Allergens (pet dander, house dust, strong
perfumes, smoking)
*85% of asthma patients test skin positive to
common allergens.
*Allergen-impermeable pillow and mattress
covers, weekly washing bedding in hot water,
air sanitizers/humidifiers, leave when
vaccuming is done, etc.

21. *
*Patient education:
*Teach early recognition of signs and symptoms.
*Improve compliance with medication.
*Seek prompt treatment when necessary.
*Prompt management of:
allergic rhinitis
sinusitis
gastroesophageal reflux
*May exacerbate asthma symptom.s

22. *
*Monitoring lung function:
*Spirometer
*FEV1 after a maximal inspiration is the single
best measure of pulmonary function.

23. *The Peak Expiratory Flow Rate
(PEFR) correlates well with the
FEV1.
*Measured reliably with
inexpensive, disposable, portable
peak flow meters.
*Insight to course of asthma
throughout the day.
*Help detect early signs of
deterioration.
*Twice daily.
*Upon awakening and after 12 hr.
*

24. *
*The typical PEFR in
pregnancy should be
380–550 L/min.
*Patient should
establish her
“personal best” PEFR,
then calculate her
individualized PEFR.
*Green Zone more than
80% of personal best.
*Yellow Zone 50 to 80%
of personal best.
*Red Zone less than
50% of personal best
PEFR.

25. *
*Adequate pharmacologic therapy
*Well controlled:
*No limitations of activity.
*None or minimal daytime symptoms.
*No nocturnal symptoms.
*No (or minimal) need for rescue medication.
*Normal lung function.
*No exacerbations.

26. *
*Step wise management to therapy: step up to
more intensive therapy if not controlled.
* Based on asthma severity (initial assessment.)
* Level of control (subsequent evaluations).
*Treat asthma aggressively.
*Attaining peak expiratory flow rate or forced
expiratory volume in 1 second of 70% or >
predicted value.

27. *
*Step-care
*Use least amount of drug to control a patient’s
asthma.
* Increases number and frequency of
medications with increasing asthma severity.
* Safer to be treated appropriately than have
asthma symptoms and exacerbations.
*Maintaining adequate oxygenation of the fetus.
*Prevention of hypoxic episodes in the mother.

28. *
*Pharmacology Management
*Relievers
*Controllers

29. *
*Relievers
*Bronchodilators: short-acting inhaled β 2-
adrenergic receptor agonist used for the
relief of bronchospasm.
*Short-acting: rapid relief of symptoms by
relaxing airways and reducing
bronchospasm.
*No anti-inflammatory action.
*They do not block the development of
airway hyperresponsiveness.
*Ex: Albuterol (Proventil, Ventolin,
Salbutamol)
* Metaproterenol (Alupent)

30. *
*Controllers:
*Control inflammation and treat disease.
*Reduce the risk of Asthma attack and airway
remodeling.
*Mainly anti-inflammatory.
*Inhaled corticosteroids
*LABA
*Cromolyn
*Theophylline
*Leukotrene antagonists

31. *
*Glucocorticoids:
*Inhaled:
*Preferred treatment for all persistent asthma levels.
*Anti-inflammatory reduce pulmonary response to
allergens.
*Beclomethasone (Qvar)
* ** Budesonide (Pulmicort) Class B
* Fluticasone (Flovent)

32. *
*Longer-acting bronchodilators. (LABA)
*Used for long term control of asthma, usually
in combination with an inhaled glucocorticoid.
(Advair, Symbicort).
*Not for rapid relief of symptoms.
*Ex: Salmeterol (Servent)
* Formoterol (Foradil)

33. *
*Cromolyn sodium:
* Is virtually devoid of significant side effects
*Blocks both the early and late phase pulmonary
response to allergen challenge.
* Preventing the development of airway
hyperresponsiveness.
*Alternative treatment for mild persistent
asthma.
*Does not have any intrinsic bronchodilator or
antihistaminic activity.

34. *
*Theophylline
* Alternative treatment for mild persistent.
* Adjunctive treatment for the management of
moderate and severe persistent asthma during
pregnancy.
*Adverse theophylline effects including,
insomnia, heartburn, palpitations, and nausea,
may be difficult to differentiate from typical
pregnancy symptoms.
* High doses have been observed to cause
jitteriness, tachycardia, and vomiting in
mothers and neonates.
*New dosing guidelines have recommended that
serum theophylline concentrations be
maintained at 5–12 µg/mL during pregnancy.
(Yeh TF, Pildes RS. Transplacental aminophylline toxicity in a neonate [letter].
Lancet 1977;1:910).49

35. *
*Leukotriene Moderators
* Arachidonic acid metabolites reduce
bronchospasm, mucous secretion and increased
vascular permeabilit.y
*Improve pulmonary function significantly as
measured by FEV1.
* An alternative treatment for mild persistent and an
adjunctive treatment for the management of
moderate and severe persistent asthma.
*Ex: zafirlukast (Accolate)
* montelukast (Singulair)
*Pregnancy category B.
* Minimal data regarding the efficacy or safety of
these agents during human pregnancy.

36. *
*Mild intermittent
*Mild persistent
*Moderate persistent
*Severe persistent
*PRN Salbutamol
*Inhaled corticoteroid
*Inhaled corticoteroid +
LABA
*Inhaled corticoteroid +
LABA

37. *
*Oral Corticisreroids
*Burst may be needed for exacerbations.
*Especially if inciting incident can be identified.
*Oral prednisone 40-60 mg/d X 7 days
*Then taper over 7-14 days.
*Data on risk of congenital anomalies
conflicting, ? Cleft lip/palate if < 13 weeks.

38. *
* Management
* Patients with moderate and severe asthma should be
considered high risk for pregnancy complications.
* Adverse outcomes can be increased by underestimation of
asthma severity and undertreatment of asthma.
* The first prenatal visit should include a detailed medical
history with attention to medical conditions that could
complicate the management of asthma, including active
pulmonary disease.
* Question smoking history, presence and severity of
symptoms, episodes of nocturnal asthma, days of work
missed, emergency care visits, hospitalizations and
intubations.
* The type and amount of asthma medications.

39. *
*Identifying and avoiding asthma triggers.
* Scheduling of prenatal visits based upon clinical
severity
* Pulmonary function (FEV1 or PEFR) are
recommended.
*Because asthma has been associated with
intrauterine growth restriction and preterm birth, it
is useful to establish pregnancy dating accurately
by first trimester ultrasonography where possible.

40. *
*Antepartum Survellience
*Pregnancies complicated by moderate or
severe asthma:
* Ultrasound for fetal growth
*Antenatal assessment of fetal well-being
(about 32 weeks).
*Asthma medications should be continued
during labor.
*Encourage breastfeeding.

41. *
* Home Management of Asthma Exacerbations
*An asthma exacerbation that causes minimal problems for
the mother may have severe sequelae for the fetus.
* Indeed, abnormal fetal heart rate tracing may be the initial
manifestation of an asthmatic exacerbation.
*Therefore, asthma exacerbations in pregnancy should be
aggressively managed.
*Patients should be given an individualized guide for decision
making and rescue management.
* Educated to recognize signs and symptoms of early asthma
exacerbations
such as coughing, chest tightness, dyspnea, or wheezing.
20% decrease in their PEFR.

42. *
*Patients should use inhaled albuterol 2–4 puffs every
20 minutes up to one hour.
*A good response is considered if symptoms are
resolved or become subjectively mild and normal
activities can be resumed.
* PEFR is more than 70% of personal best. May
continue inhaled albuterol 2–4 puffs MDI every 3–4
hours as needed.
*The patient should seek further medical attention if
the response is incomplete, or if fetal activity is
decreased.

43. *
*Incomplete response:
*PEFR is 50–80% predicted.
* Persistent wheezing and shortness of breath,
then repeat albuterol treatment 2–4 puffs MDI
at 20-minute intervals up to two more times.
* If repeat PEFR 50–80% predicted or if
decreased fetal movement, contact caregiver
or go for emergency care.

44. *
*Poor response:
*PEFR less than 50% predicted, or severe
wheezing and shortness of breath, or
decreased fetal movement.
*Repeat albuterol 2–4 puffs by MDI and
obtain emergency care.

45. *
*Emergency Department and Hospital-Based
Management of Asthma Exacerbation
*Initial assessment and treatment
• History and examination (auscultation, use of
accessory muscles, heart rate, respiratory rate
*Peak expiratory flow rate (PEFR) or forced
expiratory volume in 1 second (FEsaV1), oxygen
saturation, ABG if < 95%.
* Initiate fetal assessment (consider fetal
monitoring and/or biophysical profile if fetus is
potentially viable)

46. *
*• Albuterol by metered-dose inhaler or nebulizer, up
to three doses in first hour
*• Oral corticosteroid if no immediate response or if
patient recently treated with systemic
corticosteroid.
*• Oxygen to maintain saturation more than 95%
*• Repeat assessment: symptoms, physical
examination, PEFR, oxygen saturation
*• Continue albuterol every 60 minutes for 1–3 hours
provided there is improvement
*• Continue fetal assessment

47. *
*Good response
*• FEV1 or PEFR 70% or more
*• Response sustained 60 minutes after last
treatment
*• No distress
*• Physical examination is normal
*• Reassuring fetal status
*• Discharge home

48. *
*Incomplete response
*• FEV1 or PEFR 50% or more but less than 70%
*• Mild or moderate symptoms
*• Continue fetal assessment until patient is
stabilized
*• Monitor FEV1 or PEFR, oxygen saturation,
pulse
*• Individualize decision for hospitalization

49. *
*Poor response
*• FEV1 or PEFR less than 50%
*• Pco2 more than 42 mm Hg
*• Physical examination: symptoms severe,
drowsiness, confusion
*• Continue fetal assessment
*• Admit to intensive care unit Intravenous
corticosteroid

50. *
*Early assessment
*Implement patient education
and involvement
*Aggressively manage
*Close surveillance
*Aware of worsening
conditions
*Treat all phases of asthma as
potential complications