ASTHMA Dr.D.Rispa Assistant Professor - PowerPoint Presentation

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ASTHMA

Dr.D.RispaAssistant ProfessorDepartment Of Pharmacy Practice

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DEFINITION

Asthma is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm.

The inside walls of an asthmatic's airways are swollen or inflamed. This swelling or inflammation makes the airways extremely sensitive to irritations and increases your susceptibility to an allergic reaction.

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EPIDEOMOLOGY

According to recent estimates, asthma affects 300 million people in the world and more than 22 million in the United States. Although people of all ages suffer from the disease, it most often starts in childhood, currently affecting 6 million children in the US.

Asthma kills about 255,000 people worldwide every year.

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Children at Risk:

Asthma is the most common chronic disease among children - especially children who have low birth weight, are exposed to tobacco smoke, are black, and are raised in a low-income environment. Most children first present symptoms around 5 years of age, generally beginning as frequent episodes of wheezing with respiratory infections. Additional risk factors for children include having allergies, the allergic skin condition eczema, or parents with asthma.

Young boys are more likely to develop asthma than young girls, but this trend reverses during adulthood. Researchers hypothesize that this is due to the smaller size of a young male's airway compared to a young female's airway, leading to a higher risk of wheezing after a viral infection.

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ETIOLOGY

AllergiesTobacco smokeEnvironmental factorsPregnancyObesityStrees

Genes

Atopy

Airway

hyperreactivity

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TYPES OF ASTHMA

Components

of severity

Intermittent

Mild

Moderate

Severe

Symptoms

≤ 2 days/week

>2days/week

but not daily

Daily

Through

out

the day

Nighttime

awakenings

≤ 2x/month

3-4x/month

> 1x/week but not nightly

Often

7x/week

SABA use for

symptom

control

≤ 2 days/week

>

2 days/week but not daily

Daily

Several times per day

Interference

with normal

activity

none

Minor

limitation

Some

limitation

Extremely

limited

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Lung function

Normal FEV1 between exacerbations

FEV1>80% predicted

FEV1/FVC>85%

FEV1>80%

predicted

FEV1/FVC>80%

FEV1=60%-80%

predicted

FEV1/FVC 75-80%

FEV1<60%

predicted

FEV1/FVC<75%

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Signs and Symptoms

Bumps on skin Memory lossHeadache

Shortness of breath

Chest pain

Cough

Wheezing

Chest tightness

Chills

Jaundice

Confusion

Dizziness

Amnesia

Hairloss

Palpitations

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PATHOPHYSIOLOGY

Allergens cause an early phase allergic reaction characterized by activation of cells bearing allergens specific IgE antibodies.

There is rapid activation of airway mast cells and

macrophages,which

release

proinflammatory

mediaters

such as histamine and

eicosanoids

that induce contraction of airway smooth

muscle,mucus

secretion,vasodilation

and exudation of plasma in the airways.

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The late phase inflammatory reaction occurs 6-9 hours after allergen provocation and involves recruitment and activation of

eosinophils, T-lymphocytes, basophils, neutrophils and macrophages.Eosinophils migrate to the airways and release inflammatory mediators, cytotoxic

mediators and cytokines.

T-

lympocytes

activation leads to release of cytokines from type-2 (T

H

-2

) T-helper cells that mediate allergic inflammation (interleukin IL-4,5,6,9 &13). Conversely, type-1 T-helper cells produce IL-2 and interferon

γ

that are essential for cellular

defence

mechanism.allergic

asthamatic

inflammation may result from an imbalance between T

H

-1 and T

H

-2.

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DIAGNOSIS

Asthma diagnoses are based on three core components: a medical history, a physical exam, and results from breathing tests. The different tests perform to identify asthma are given below

Medical history

Physical exam

Asthma tests

Other tests

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Medical history

Family history of asthma and allergies can help make an accurate asthma diagnosis.Information about asthma symptoms like wheezing, coughing, chest tightness, breathing difficulty are also useful to diagnose asthma.

It is also wise to make note of health conditions that can interfere with asthma management such as runny nose, sinus infections, acid reflux disease, psychological stress, and sleep apnea.

It is often somewhat harder to diagnose young children who may develop their first asthma symptoms before age 5. Symptoms are likely to be confused with those of other childhood conditions, but young children with wheezing episodes during colds or respiratory infections are likely to develop asthma after 6 years of age.

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Physical examination

A physical examination will generally focus on the upper respiratory tract, chest, and skin. A doctor will use a stethoscope to listen for signs of asthma in your lungs as you breathe. The high-pitched whistling sound while you exhale - or wheezing - is a key sign of both an obstructed airway and asthma.

Physicians will also check for a runny nose, swollen nasal passages, and nasal polyps. Skin will be examined for conditions such as eczema and hives, which have been linked to asthma.

Physical symptoms are not always present in asthma sufferers, and it is possible to have asthma without presenting any physical maladies during an examination.

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Asthma tests

Lung function tests, or pulmonary function tests, are the third component of an asthma diagnosis. To measure how much air you breathe in and out and how fast you can blow air out, physicians administer a

spirometry

test.

Spirometry

is a noninvasive test that requires you to take deep breaths and forcefully exhale into a hose connected to a machine called a

spirometer

. The

spirometer

then displays two key measurements:

Forced vital capacity (FVC) - the maximum amount of air one can inhale and exhale.

Forced expiratory volume (FEV-1) - the maximum amount of air exhaled in one second

The measurements are compared against standards developed for a person's age, and measurements below normal may indicate obstructed airways.

Children younger than 5 years of age are difficult to test using

spirometry

, so asthma diagnoses will rely mostly on symptoms, medical histories, and other parts of the physical examination

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Other tests

A "Challenge Test" (bronchoprovocation test) is when a physician administers an airway-constricting substance to deliberately trigger airway obstruction and asthma symptoms. Similarly, a challenge test for exercise-induced asthma would consist of vigorous exercise to trigger symptoms. A

spirometry

test is then administered, and if measurements are still normal, an asthma diagnosis is unlikely.

A new test using exhaled nitric oxide is being evaluated test that is more accurate than

spirometry

. Higher levels of nitric oxide are linked to higher degrees of asthma severity. The current drawback lies in the high cost of the test and the specialized equipment required to measure this chemical marker.

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TREATMENT

CLASSIFICATION:

Bronchodilators

A.

Beta2

sympathomimetics

:

Salbutamol,

Terbutaline

,

Bambuterol

,

Salmeterol

,

Formoterol

, Ephedrine.

B.

Methylxanthines

: Theophylline, Aminophylline, Choline

theophyllinate

,

Hydroxy

ethyl

theophilline

,

Doxophylline

.

C.

Anticholinergics

: Ipratropium bromide,

Tiotropium

bromide.

Leukotriene antagonists

:

Montelukast

,

Zafirlukast

.

Mast cell stabilizers

:

Sodium

cromoglycate

,

Ketotifen

.

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Corticosteriods

: A.Systemic: Hydrocortisone, Prednisolone.

B.Inhalational

:

Beclomethasone

,

Dipropionate

, Budesonide,

Flunisolide

,

Ciclesonide

.

Anti-

IgE

antibody:

Omalizumab

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Bronchodilators

Salbutamol MOA: beta2 receptor stimulation  increased

cAMP

formation in bronchial muscle cell  relaxation.

CI: Hypersensitivity.

Dose: 100mcg

b.d

by inhalation.

ADR’s: headache, nervousness, allergy.

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Theophylline: MOA: release of Ca2+ from sarcoplasmic reticulum

 inhibition of

phosphodiester

which degrades cyclic nucleotides

intracellularly

. Concentration of cyclic nucleotides is increased.

Brochodilatation

occur when

cAMP

level rises in the concerned cells.

DOSE: 400-1600 mg/day in divided

dose orally.

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Ipratropium bromide It is an inhalational antimuscarinic drug which

action is restricted to lungs.

MOA:

Blocks

cholinergic receptors present on

bronchial

smooth muscles –›

inhibits

acetylcholine action

(bronchoconstriction)

–›

leading

to

bronchodilation

.

DI: belladonna and betel nut.

CI: hypersensitivity to

atropin

.

ADR’s: nausea, headache, dry mouth, dizziness, GI

upsets.

DOSE:

Ipratropium bromide: (inhalation solution 0.02%) 500 mcg

NEBULIZED

3 to 4 times per day; separate doses by 6 to 8 hours

.

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Leukotriene antagonists

: Montelukast:

MOA: it binds with high affinity to the

LTD4 inhibiting bronchoconstriction.

CI: hypersensitivity.

DI: Phenytoin, rifampicin,

cabamazepine

, decreases the plasma concentration of

montelukast

.

ADR’s:

angio

oedema

and skin rashes.

DOSE: adults 10 mg tab OD

children 6-14 years 5 mg OD, 2-5 years 2 mg OD.

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Mast cell stabilizers

: Ketotifen: MOA: inhibit enzyme

phosphodiesterase

,

blocks calcium channels and inhibit

the release of histamine and SRS-A.

DI: Potentiate effects of

sedtive

, hypnotics,

anti histamines and alcohol.

ADR’s: dizziness, drowsiness.

DOSE: 1-2 mg BD, children 0.5 mg BD.

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Corticosteroids

: Budesonide MOA:

Reduction

in capillary permeability to decrease mucus

Inhibition of release of

proteolytic

enzymes from leukocytes

Inhibition of prostaglandins

DOSE:100-200 mcg bid, max.1600 mcg/day

(adult). Children 50-100 mcg bid, max.

800 mcg/day.

ADR’s: mild irritation, candidiasis,

dyspnoea

.

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TYPES OF INHALERS:

Metered dose inhaler.MDI with a spacer- asthma in children.

Dry powered inhalers- breath activated inhalers.

Blue inhalers- bronchodilator drugs.

Brown inhaler- steroid drug.

Long acting asthma inhalers- bronchodilator drugs.

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How to use inhaler

Wash your hands thoroughly with soup and warm water.Remove the cap and hold the inhaler upright.Shake the inhaler.

Breath out slowly through your mouth.

Hold your inhaler as shown

in the picture or as recommended

by your doctor.

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While your breathing in, press down on your inhaler one time to release the medication.

Continue to breath in slowly and as deeply as you can.Hold your breath for 10 sec, if u can, to allow the medication to reach deeply in to your lungs.Repeat steps 3 and 8 until you have inhaled the number of puffs that your doctor prescribed. Ask your doctor or pharmacist you need to wait between the puffs of your medication.

Rinse your mouth thoroughly with water.

Split out the water. Do not swallow.

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PREVENTION

Follow your asthma action plan.Get immunizations for influenza and pneumonia.

Identify and avoid asthma triggers.

Monitor your breathing.

Identify and treat attacks early.

Take your medication as prescribed.

Pay attention to increasing quick-relief inhaler use.

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RISK FACTORS

A number of factors are thought to increase your chance of developing asthma are given below

Having a blood relative with asthma.

Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever).

Being overweight.

Being a smoker.

Exposure to secondhand smoke.

Having a mother who smoked while pregnant.

Exposure to exhaust fumes or other types of pollution.

Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing.

Low birth weight.

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NON PHARMACOLOGICAL TREATMENT

Nutrition and healthy eating.Birth control.Weight loss.Sexual health.

Fitness.

Quit smoking.

Stress management.

Consumer health.

Avoid second

hand smoking.

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THANK YOU