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Review of Pathophysiology and



• Chronic inflammatory disease of the


• Most common childhood chronic


• Affects ~4.8 million (CDC, 1995)

• >100 million days of restricted activity

• 470,000 hospitalizations/yr


• >5000 deaths annually

– Highest in blacks ages 15-24

• Hospitalizations highest in blacks &


Pathogenesis and Definition

• Key points

– Chronic inflammatory disorder of the


– Immunohistopathologic features

denudation of airway epithelium

collagen deposition beneath basement



mast cell activation

– Immunohistopathologic features

inflammatory cell infiltration

– Neutrophils (sudden, fatal asthma)

– Eosinophils

– Lymphocytes

• Airway inflammation (AI) contributes to

hyperresponsiveness, airflow limitation,

symptoms & chronicity

• AI causes types of airflow limitation:

– Bronchoconstriction, edema, mucus plug

formation, airway wall remodeling

• Atopy is strongest predisposing factor

for developing asthma

• Working definition of asthma (1995,


Asthma is a chronic inflammatory

disorder of the airways in which many

cells & cellular elements play a role

(mast cells, eosinophils, T lymphocytes,

macrophages, neutrophils, & epithelial


– In susceptible individuals , inflammation

causes recurrent episodes of wheezing,

breathlessness, chest tightness, and

coughing, particularly at night/early

morning. These episodes are associated

with variable airflow obstruction often

reversible spontaneously/treatment

• Child-onset asthma

– Associated with atopy

– IgE directed against common

environmental antigens (house-dust

mites, animal proteins, fungi

– Viral wheezing Infants/children,

allergy/allergy history associated with

continuing asthma through childhood

• Adult-onset asthma

– Many situations

– Allergens important

– Non-IgE asthma have nasal polyps,

sinusitis, aspirin sensitivity or NSAID


– Idiosyncratic asthma less understood

• Adult-onset asthma

– Occupational exposure

animal products, biological enzymes, plastic

resin, wood dusts, metal

removal from workplace may improve

symptoms although symptoms persist in some

Airway Inflammation & Lung


• The cells that influence &/or regulate

inflammation results in different types of


– Acute - early recruitment of cells

– Subacute - cells activated to cause more

persistent inflammatory pattern

– Chronic - persistent level of cell damage

& repair. Abnormal changes may be


Airway Inflammation & Lung


• Airway hyperresponsiveness

– Exaggerated bronchoconstrictor response

– Post exposure wheezing & dyspnea

– Degree correlates to asthma severity

– Measured by methacholine/histamine

inhalation challenge or non-drug stimuli

(cold, dry air)

• Airway hyperresponsiveness

– Correlation to airway inflammation clear

but complex

airway inflammation markers

tx. of asthma & modification of ai markers

reduce symptoms & hyperresponsiveness

• Airflow limitation

– Acute bronchoconstriction

IgE -dependent mediator release from mast

cell (leukotrienes, histamine, tryptase,


aspirin /NSAID

non-IgE response (cold air, exercise, irritants)

• Airflow limitation

– Acute bronchoconstriction

stress - mechanisms ??

Airway edema


– increase microvascular permeability/


– mucosal thickening & airway swelling

airway rigidity

• Airflow limitation

– Chronic mucus plug formation

secretions & inspissated plugs

persistent airflow limitation in severe intractable


– Airway remodeling

irreversible component of airflow limitation

secondary to structural airway matrix changes

• Airflow limitation

– Airway remodeling

attributed to chronic, severe airway


early intervention with anti-inflammatory

therapy suggests prevention of permanent

airflow limitation

Measures of Assessment and


Asthma diagnosis criteria

– + episodic symptoms of airflow obstruction

– Airflow obstruction partially reversible

– R/O alternative dx

• Techniques to establish diagnosis

– History

– Physical exam (resp. tract, skin, chest)

– Spirometry to demonstrate reversibility

– Additional studies :

evaluate alternative dx., ID precipitating factors

assess severity, ID potential complications

Asthma Specialist

• Differences from 1991 Expert Panel

– Severity classifications:

mild intermittent

mild persistent

moderate persistent

severe persistent

– Questions added to aid dx & assessment

– Referral criteria refined

– PEF diurnal variation recommendations

Severe Persistent Asthma

• Symptoms

– Continual

– Limited physical


– Frequent


– Frequent nighttime


• Lung Function

– FEV 1 or PEF < 60%

of predicted

– PEF variability


Moderate Persistent Asthma

• Symptoms

– Daily symptoms

– Daily use of inhaled


beta 2 agonist

– Exacerbations

affect activity; > 2

X/wk; may last days

– Nighttime

symptoms >1


• Lung Function

– FEV 1 or PEF

> 60% - < 80%


– PEF variability


Mild Persistent Asthma

• Symptoms

– Symptoms > 2 X/wk

but 2 X/mo

• Lung Function

– FEV 1 or PEF > 80%


– PEF variability


Mild Intermittent Asthma

• Symptoms

– Symptoms < 2 X/wk

– Asymptomatic and

normal PEF



– Exacerbations brief

(few hrs - few

days); intensity

may vary

– Nighttime

symptoms < 2 X/mo

• Lung Function

– FEV 1 or PEF > 80%


– PEF variability

< 20%

Asthma Management

• Goals of therapy

– Prevent symptoms

– Maintain (near) “normal” PF

– Maintain normal activity

– Prevent exacerbations & minimize ER


– Optimal drug tx, minimal problems

– Patient/family satisfaction

• Recommended monitoring

– S & S


– Quality of life/functional status

– Exacerbations

– Drugs

– Patient/provider communication &


• Monitor using clinician assessment/pt.


• Spirometry tests

– Initial assessment

– Post tx after patient’s symptoms and PF


– Minimally Q 1-2 yrs

• Written action plan based on:

– Signs & symptoms &/or PEF

• Patient education:

– Recognition need for additional therapy

• Patient education:

– How & when to do PF monitoring

Differences from 1991 Panel

• Added patient/family satisfaction to

treatment goals

• Periodic assessment of 6 domains of

patient health are recommended:

– S&S, PF, quality of life, hx. of

exacerbations, pharmacotherapy,

pt./provider communication, pt. satisfaction

• PF measurements changes

– Changed from 2 X daily to morning

– If morning

Assessment Measures

Asthma treatment effectiveness

– Monitor signs & symptoms - daytime,

nocturnal, early morning symptoms

response to short-acting Beta agonist

– Pulmonary function (spirometry, PF)

patients with moderate-to-severe persistent

asthma should learn how to monitor PEF at


PF during exacerbations in pts. with moderateto-severe

asthma is recommended

Asthma treatment effectiveness

– PF monitoring

long term daily PF monitoring in moderate-tosevere

asthma is helpful

if long-term PF monitoring is NOT used, short

term period of PF monitoring is recommended

– establish individual’s personal best

– identify time relationships between changes

in PF to exposure

– evaluate response to chronic maintenance


• Personal best

– 2-3 wk period pt. records early afternoon


– Measure after each use of short-acting

beta-2 agonist for symptom relief

– ? course of oral steroids to establish

personal best

– Don’t use outlyer PEF values

Asthma treatment effectiveness

– Monitoring quality of life/functional status

missed work, school



changes in caregivers activities due to child’s


– Monitoring asthma exacerbation history

self-treated, or by HC providers

Asthma treatment effectiveness

– Monitoring asthma exacerbation history

unscheduled visits/telephone calls/urgent or

emergent care

frequency, severity & causes of exacerbations

hospitalization info - length of stay, intubation,


Asthma treatment effectiveness

– Monitoring Drug Therapy

patient compliance

inhaler technique

frequency of use the short-acting beta2 agonist

frequency of oral steroid “burst” therapy

dose changes of inhaled anti-inflammatory


Asthma treatment effectiveness

– Periodic assessment by clinician and


clinician assessment

– medical history and physical exam with PFT

– mild intermittent-to-mild persistent asthma

under control for 3 mos. should be

reassessed Q 6 mos

– uncontrolled &/or severe persistent should

be seen more often

Asthma treatment effectiveness

– Periodic assessment by clinician and


patient self-assessment

– daily diary - symptoms, PF, med. use

– periodic self-assessment filled out at the

time of the clinic visit - self perception of

asthma control, self-skills, satisfaction

population based assessment - HMO’s

Pharmacologic Therapy

• Long-term control medications

– corticosteroids

inhaled form

systemic steroids used to gain prompt control

of disease when initiating inhaled tx

– cromolyn sodium or nedocromil

mild-to-moderate anti-inflammatory medications

(may be used initially in children)

preventive tx. prior to exercise or unavoidable

exposure to known allergens

• Long-term control medications

– Long-acting beta2-agonists

used concomitantly with anti-inflammatory

meds for long-term symptom control especially

nocturnal symptoms

prevents exercise-induced bronchospasm

– Methylxanthines

sustained-release theophylline used as

adjuvant to inhaled steroids for prevention of

nocturnal symptoms

• Long-term control medications

– Leukotriene modifiers

zafirlukast - leukotriene receptor antagonist

zileuton - 5-lipoxygenase inhibitor is alternative

therapy to low doses of inhaled


alternative tx to low dose inhaled


recommended for >12yrs with mild persistent

asthma. Further study needed

• Quick relief medications

– Short acting beta2-agonists - relief of acute


– Anticholinergics - may provide additive benefit

to beta2 drugs in severe exacerbation. May be

alternative to beta2-agonists

– Systemic steroids - moderate-to-severe

persistent asthma in acute exacerbations or to

prevent recurrence of exacerbations

Treatment/Long Term Control

• Corticosteroids

– Most potent and effective

– Reduction in symptoms, improvement in

PEF and spirometry, diminished airway

hyperresponsiveness, prevention of

exacerbations, possible prevention of

airway wall remodeling

– Suppresses: cytosine production, airway

eosinophilic recruitment, chemical mediators

• Corticosteroids

– Dose dependent on product and delivery


– 2 X/day use is common in moderate-tosevere

persistent asthma

– 1 or 2 X/day may be used in mild persistent


• Cromolyn & nedocromil

– Have distinctive properties

– Similar anti-inflammatory reactions

blocks Cl - channels

modulate mast cell mediator release

modulate eosinophilic recruitment

inhibits early and late asthmatic response to

antigen challenge

• Cromolyn & nedocromil

– Similar anti-inflammatory reactions

inhibits bronchospasm (exercise, cold dry air,

bradykinin aerosol)

nedocromil more potent in inhibiting

bronchospasm in the above situations

– Both reduce asthma symptoms

improve PF

reduce need for short acting beta2 agonists

• Cromolyn & nedocromil

– Dosing requirements

recommended for both 4 X/day

nedocromil effective at 2 X/day

– Clinical response for both is less

predictable than steroids

– Both have strong safety profile

• Long-acting beta- 2 agonists

– Relax airway smooth muscle

– Duration of action >12 hrs

– Not used in acute exacerbations

– Adjunct to anti-inflammatory tx for longterm

symptom control especially nocturnal


• Methylxanthines

– Provides mild-moderate bronchodilation

– Low dose has mild anti-inflammatory action

– Sustained release form used as alternative

but not preferred to long-acting beta 2

agonists to control nocturnal symptoms

– Use may be necessary because of cost or

patient compliance

• Leukotriene modifiers

– Leukotrienes are potent biochemical

mediators released from mast cells,

eosinophils, and basophils that:

contract bronchial smooth muscle

increase vascular permeability

increase mucus secretions

attract & activate inflammatory cells in airways

• Leukotriene modifiers

– Zafirlukast & zileuton (oral tabs)

improves lung fx and diminishes symptoms &

need for short-acting beta 2 agonists

– Studies in mild-moderate asthma showing

modest improvements

– Alternative to low-dose inhaled steroids for

pts. with mild persistent asthma

– Further study in of other groups needed

• Leukotriene modifiers

– Zafirlukast - leuktriene receptor antagonist

attenuates late response to inhaled allergen

and post-allergen induced bronchospasm

modest improvement in FEV 1 (11% > placebo)

improved symptoms

reduced albuterol use

– Warning - increases warfarin half-life and

PT & PTT must be monitored with dose

adjustment when indicated

• Leukotriene modifiers

– Zileuton - 5-lipoxygenase inhibitor

provides immediate & sustained improvement

in FEV 1 (mean 15% > placebo) in mild-tomoderate


moderate asthmatics had fewer exacerbations

requiring oral steroids

attenuates bronchospasm from exercise & from

aspirin in sensitive people

inhibits metabolism of theophylline, warfarin,

terfenadine and must be monitored

Asthma Treatment/Quick Relief

• Short-acting beta 2 agonists

– Relax airway smooth muscle and increase

in airflow in 1 canister/mo indicates

inadequate control and indicates need to

intensify anti-inflammatory tx

– Regularly scheduled use NOT


• Anticholinergics

– Cholinergic innervation important in

regulation of airway smooth muscle tone

– Ipratropium bromide (quaternary derivative

of atropine without its’ side effects)

– Additive benefit with inhaled beta 2 -

agonists in severe asthma exacerbations

– Effectiveness in long-term management

not demonstrated

• Systemic steroids

– speed resolution of airflow obstruction

– reduce rate of relapse

• Medications to reduce oral steroid


– Troleandomycin, cyclosporin, gold,

methotrexate, IV immunoglobulin,

dapsone, hydroxychloroquine

• Medications to reduce oral steroid


– Recommended use in pts. under

supervision of asthma specialist

– Complicated application because of

variable effects, potential toxicity, & limited

clinical experience

Intermittent Asthma

• Step 1

– Short-acting inhaled beta 2 agonists PRN



(exception is EIB or viral infections)

– Viral infections

mild symptoms - beta 2 agonist Q 4-6 hr

moderate-to-severe symptoms - short course of

systemic steroids recommended plus above

Persistent Asthma

• Mild, moderate or severe

– Daily long-term control recommended

• Mild persistent asthma (step 2 care)

– Daily anti-inflammatory meds - inhaled

steroids (low dose) or cromolyn or


– Sustained release theophylline alternative

but not preferred

• Mild persistent asthma (step 2 care)

– Zafirlukast or zileuton considered in pts.

>12 yrs

– Quick relief medications must be available

short-acting beta 2 agonists

intensity depends upon severity of exacerbation

• Moderate persistent asthma (step 3


– Increase inhaled steroids to medium dose


– Add long-acting bronchodilator to a lowmedium

dose of inhaled steroids


– Increase to medium dose steroid then

lower dose & add nedocromil (+/-)

• Moderate persistent asthma (if not

adequately controlled)

– Increase to high dose inhaled steroids &

add long-acting bronchodilator (serevent or


• Severe persistent asthma (step 4)

– If not controlled on high dose of inhaled

steroids and long-acting bronchodilator

ADD oral systemic steroids on a

regularly scheduled, long-term basis

use lowest dose

monitor closely

attempt to reduce or take off when control


Infants and Young Children

• Diagnosis difficult

– If suspected a diagnostic trial of inhaled

bronchodilators and anti-inflammatory

drugs may be helpful

• Infants & young children ( 2x/wk start daily

anti-inflammatory therapy

• Infants & young children

Trial of cromolyn or nedocromil (low dose

inhaled steroids are alternative)

Monitor response to anti-inflammatory tx

– After control established, attempt step down


– Step 3 care

Higher dose steroids to establish control - step

down in 2-3 mos. ~ add nedocromil or

theophylline instead of increasing steroid

• Infants & young children

– Exacerbations by viral infections

consider systemic steroids

– Consider consultation with asthma

specialist in those requiring step 2 care

– Should consult with asthma specialist in

those requiring step 3 care

Emergency Department


• Start treatment when asthma

exacerbation recognized

• While tx is being given:

– Take a more detailed history

– Complete physical examination

– Perform laboratory studies

PEF on presentation, after initial tx. and at

frequent intervals)

– Perform laboratory studies

FEV 1 or PEF

– Treatment:

O 2 (Sa O 2 90-95),

inhaled short-acting bronchodilator for all pts. (3

tx Q 20 min, continuous therapy an option)

Consider anti-cholinergics

oral systemic corticosteroids (unresponsive to

initial beta 2 agonist therapy, moderate-tosevere

asthma, people who are on steroids)

systemic steroids administered when admitted

methylxanthines are not recommended

– Treatment:

Aggressive hydration NOT recommended for

older children and adults (may be necessary

with infants and sm. children)

Antibiotics NOT recommended unless infection

present (fever, purulent sputum)

CPT NOT recommended

Mucolytics NOT recommended

Sedation NOT recommended


• Decision to hospitalize depends upon:


severity (symptoms & airflow obstruction)

course & severity of previous exacerbations

medication use at time of exacerbation

access (medical care & meds)

home conditions

psychiatric illness

• Treatment:

– Emergency dept. treatment

– Intubation shouldn’t be delayed once ARF

is identified

Permission hypercapnia is recommended

ventilator strategy

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