asthma final paper1(1).pdf

7/18/2019 asthma final paper1(1).pdf

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Asthma

Treatment

Ph. Adnan Mustafa Ismail

By



1

DEFINITION

Asthma is defined as chronic inflammation and

constriction of Air ways.

Asthma is on two types:

1- Extrinsic asthma: commonly in children.2-

Intrinsic asthma: commonly in adults.

PATHOPHYSIOLOGY

To determine the pathology of asthma first we have to

identify factors that initiate, intensify, and modulate the

inflammatory response of the airways and to determine how

these processes produce the characteristic airway

abnormalities.

ACUTE INFLAMMATION

Inhaled allergen in allergic patients lead to an early-phase

reaction by activation of cells bearing allergen-specific IgE, it is

characterized by rapid activation of airway mast cells andmacrophages leading to rapid release of pro-inflammatory

mediators like histamine, eicosanoids and reactive oxygen that

induce contraction of airway smooth muscles, mucus secretion

and vasodilation.

For further reading please about (acute and chronicinflammation ) see pharmacotherapy a pathophysiologic

approach, 8th edition, page 441.



2

SIGNS AND SYMPTOMS

ACUTE SEVER ASTHMA

Signs: includes wheezing, dry cough, tachypnea, tachycardia,and pale or cyanotic skin.

Symptoms: include SOB, chest tightness, or burning, and the

patient able to say only few words in each breath.

Symptoms are unresponsive to usual measure (SABA).

CHRONIC ASTHMA

Signs: includes wheezing, dry cough, signs of atopy (allergicrhinitis and/or eczema).

Symptoms: includes dyspnea, chest tightness, whistling sound

when breathing.

These symptoms are associated with exercise, but may also

occur spontaneously or in association with known allergen.

TRIGGER FACTORS

Extrinsic: dust mites, allergen, and pollen.

Intrinsic: the trigger in this type of asthma is non-

allergenic factors like viral infection, irritant (which cause

epithelial damage and mucosal inflammation), emotional

upset (which mediate excess sympathetic input), or

exercise which cause water and heat loss from airways,

and triggering mediators release from mast cell.



3

LEVEL OF CONTROL

GINA GUIDELINES FOR ASTHMA CONTROL LEVEL

Asthmatic patients can be categorized into 3 groups according

to the level of control:

1- Controlled or totally controlled ( all of the following )

Those patients must have no or less than 2 daytime

symptoms (cough, wheezing, and chest tightness), and

Asthma doesn’t limit the ability of those patients to

perform their activates (go to school, work … etc.), their

sleep must not disturbed by nocturnal symptoms

(awakening), they should never use rescue medication

(like Ventolin) or at least use it 2 or less in one week, the

lung function must be normal, and they should have noExacerbations (need for hospitalization).



4

2-

Partly or partially controlled ( any of the following )

Those patient should have no limitation of activates or

nocturnal symptoms, have daytime symptoms of morethan 2 times in one week, use their rescue medications

more than 2 times in a week, and have one or moreexacerbations in one year.

3-

Uncontrolled patient

If three or more of partially controlled patients parameters

are present, so the patient considered uncontrolled, likehave daytime symptoms of more than 2 in one week, use

their rescue medications more than 2 in one week, and

have nocturnal symptoms.

TREATMENT

GOALS OF TREATMANT OF ASTHMA

Reducing impairment:

1-

Prevent chronic and troublesome symptoms

(soughing, breathlessness in daytime, night time, andafter exercise).

2- Need for rescue medication (≤ 2 days/week).

3-

Maintain (near) normal lung function.4- Maintain normal activity level.

Reducing risk:1-

Prevent recurrent exacerbation and visit of emergency

department.

2-

Prevent loss of lung function.

3- Minimal or no adverse effect of treatment.

NOTES

The patient must be advocated to use PEF (peak

expiratory flow rate) monitoring.

You can see the device and the values of PEF in page 10.



5

Advantage of the use of inhaled corticosteroids compared

to systemic corticosteroids is the targeted delivery of drug

to the lungs, which decreases the risk of systemic adverseeffects.

PHARMACOLOGICAL

ICS (Fluticasone) is contraindicated in patients who have

hypersensitivity to steroids and should be used cautiously in

diabetes, glaucoma, active infection and immunocompromised

patients.

Leukotriene modifier (montelukast): should be used cautiously

in patients with acute asthmatic attack, alcohol consumption, and

sever hepatic disease.

LABA (salmeterol): contraindicated as monotherapy in asthma

(i.e. should be used only in combination with ICS), sever cardiac

disease, tachycardia, and should be used cautiously in HTN,

diabetes, closed-angle glaucoma, acute asthma.

Combined ICS+LABA: see above for each component.

Theophylline: it has narrow-therapeutic index

Contraindicated in patients with tachycardia

And should be used cautiously in elderly, CHF,

hyperthyroidism, active peptic ulcer disease, and

hepatic disease.

GINA GUIDELINES FOR TREATMENT

(TREATMENT STEPS)

In the treatment of asthmatic patients we must follow the

GINA guidelines, which is a flexible strategy and give us

different alternatives in case that a drug is contraindicated or lead

to undesirable side effect.



6

GINA GUIDELINES FOR ASTHMA TREATMENT

STEP UP

Step one

A newly diagnosed patients we have to start from step one(administration of SABA like Ventolin) and monitor the effect

on the symptoms.

Step two

If the patient is not "TOTALY CONTROLLED" then we haveto move to the next step in which the patient can use his rescue

medication and give him low-dose ICS if the patient not take themedication (diabetic patients) we have to use the alternative

(LTRA).



7

Step three

If the patient is not "TOTALLY CONTROLLED" in the 2nd step

we have to, step up to the next step in this stage the patient can

use their rescue medication, and we give him Low-dose ICS +

LABA or alternative drugs. If they respond to LABA continue to

use it if not or the patient don’t like the side effect we have to use

the alternatives.

Step four

If the patient not respond to the 3rd step treatment, we have to add

either medium or high dose ICA + LABA or LTRA or Sustained

release theophylline.

Step five

If the patient dose not respond to the step 4 treatments, we have

to add systemic glucocorticosteroid.

STEP DOWN

If the patient is "TOTALLY CONTROLLE" at any step of

treatment we have to consider several months as follow up, if he

is still "TOTALLY CONTROLLED" we have to step-down, ifhe is still totally controlled we will still at that stage for several

months to evaluate his state, or if he not totally controlled (i.e his

state is not good) we have to step – up to the stage at which he

was totally controlled.



8

ASTHMA CONTROL TEST (ACT)

It is an important issue to have a tool to determine the level

of control of asthmatic patients, one of the best tool is the figure

below.

It is contain 5 questions and for each answer there is a score, after

answering each question by the patient we will have a total score.

Note: assessment interval is after 4 weeks of starting each step of

the treatment.



9



10

Green zone (80 – 100%) = Controlled.

Yellow zone (50 – 79%) = cautionary and requires increase

bronchodilator use or beginning of prednisone if not improved.

Red zone (less than 50%) = the patient should contact with

healthcare provider.



11

EXERCISE

Mr. J.A is 35 years old male presented to Tikrit Teaching

Hospital with sever SOB, drowsy, and unable to speak more thana couple of words at a time.

He complaining of flu-like symptoms and a worsening cough forthe past few days. He complain of increasing difficulty in

breathing he start to use his inhalers several times in a day for

days in a week , with no good response.

WHAT IS THE DIAGNOSIS?

AND WHAT ARE THE SYMPTOMS YOU

CONSIDERD FOR?

WHAT IS THE LEVL OF CONTROL IN THIS PATIENT?

WHICH STEP YOU SUGGEST TO STAET TREATMENT WITH? WITH

COMMENT.

REFERENCES

1-

Oxford handbook of clinical medicine 7ed.2- Pharmacotherapy a pathophysiologic approach 8ed.

3-

Mosby's nursing drug reference 27ed.

4-

Clinical pharmacy and applied therapeutics (Roger

Walker) 5ed.

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asthma final paper1(1).pdf