بسم الله الرحمن الرحيم - PowerPoint Presentation

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بسم الله الرحمن الرحيم

Respiratory Medicine

24

/10/2018

Dr.Majeed

Mohan

Alhamammi

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Objectives

Defintion

Epidemiology

Clinical presentation in emergency and outpatient.

Diagnosis

Treatment of the emergency and chronic condition.

Complication

prognosis

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To know the epidemiology ,etiology, pathogenesis ,clinical presentation, investigation ,diagnosis ,treatment ,complication ,prognosis

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Asthma

Asthma is a common chronic inflammatory condition of the lung airways whose cause is still incompletely understood.

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Asthma has three characteristics:

Airflow limitation

which is usually

reversible spontaneously

or with

treatmen

t .

Airway

hyperresponsiveness

to a wide range of stimuli .

Inflammation of the bronchi

with

eosinophils

, T lymphocytes and mast cells with associated plasma exudation, oedema, marked smooth muscle hypertrophy, mucus plugging and epithelial damage.

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Typical symptoms include

wheeze,

cough,

chest tightness

dyspnoea

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Epidemiology

 

The prevalence of asthma increased steadily.

that asthma affects 300 million people world-wide

an additional 100 million persons will be diagnosed by 2025.

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World map showing the prevalence of clinical asthma (proportion of population (%)).

Data drawn from the European Community Respiratory Health Study (ECRHS) and the International Study of Asthma and Allergies in Childhood (ISAAC).

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Classification

Asthma can be divided into:

extrinsic

- implying a definite external cause

intrinsic

or

cryptogenic

- when no causative agent can be identified.

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Extrinsic asthma

Most frequently in atopic individuals.

Atopy

or positive skin-prick tests to inhalant allergens are shown in 90% of children and 50% of adults with persistent asthma.

Childhood asthma

is often accompanied by eczema .

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Intrinsic asthma

often starts in middle age

('late onset').

 

Non-atopic

from extrinsic causes such as sensitization to occupational agents

aspirin intolerance

β-adrenoceptor-blocking agents.

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Extrinsic causes must be considered in all cases of asthma and, where possible, avoided.

Aspirin-sensitive asthma .

In exercise-induced asthma,

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Factors implicated in the development of, or protection from, asthma.

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Asthma Traditional Therapy Approach

Tattersfield

AE, et al. Am J

Respir

Care Med 1999; 160:594-9

2.

FitzGerald JM, et al. Can

Respir

J 2003; 10(8):427

Bateman et al .J Allergy Clin Immunol 2010; 125: 600-8

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Reversibility test. Forced expiratory before and 20 minutes after inhalation of a

β

2

-adrenoceptor agonist. Note the

increase in FEV

1

from 1.0 to

2.5 L

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Airway hyper-reactivity in asthma.

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Changes in peak flow following allergen challenge. A similar biphasic response is observed following a variety of different challenges. Occasionally an individual will develop an isolated late response with no early reaction

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Airway hyper-reactivity in asthma. This is demonstrated by bronchial challenge tests by the administration of sequentially increasing concentrations of either histamine,

methacholine

or

mannitol

. The reactivity of the airways is expressed as the concentration or dose of either chemical required to produce a certain decrease (usually 20%) in the FEV

1

(PC

20

or PD

20

respectively).

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.

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Diurnal pattern

Asthma characteristically displays a diurnal pattern,

with symptoms and lung function being worse in the

early morning. Particularly when poorly controlled,

symptoms such

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Serial recordings of peak expiratory flow (PEF) in a patient with asthma. Note the sharp overnight fall (morning dip) and subsequent rise during the day. In this example corticosteroids have been commenced, followed by a subsequent improvement in PEF rate and loss of morning dipping.

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Exercise-induced asthma.

Serial recordings of FEV

1

in a patient with bronchial asthma before and after 6 minutes of strenuous exercise. Note initial slight rise on completion of exercise, followed by sudden fall and gradual recovery. Adequate warm-up exercise or pre-treatment with a β

2

-adrenoceptor agonist,

nedocromil

sodium or a

leukotriene

antagonist (e.g.

montelukast

sodium) can protect against time

in minute

)

exercise-induced symptoms.

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Making a diagnosis of asthma

Compatible clinical history

plus either/or

: FEV

1

≥ 15%* (and 200 mL) increase following administration of a bronchodilator/trial of corticosteroids

> 20% diurnal variation on ≥ 3 days in a week for 2 weeks on PEF diary

FEV

1

≥ 15% decrease after 6

mins

of exercise

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Signs

Depend on severity

Conscious level normal-………. coma

Respiratory rate normal-

tachypnoea

-…….

apnoea

Blood pressure hypertension(

vasculitis

) paradox

Pulse rate

Position

Chest examination normal in mild type

hyperinflation in chronic one

Prolonged expiration

exp,inspiratory

rhonchi

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Level of asthma control

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Management approach based on asthma control.

For children older than 5 years, adolescents and adults. (ICS = inhaled corticosteroid) *Receptor antagonist or synthesis

inhibitors

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How to use a metered-dose inhaler.

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Step 3: assess inhaler technique

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Step 4: assess patient adherence to treatment

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Step 5: exclude alternative or overlapping diagnosis as primary conditions

Step 6:

Identify and treat co-morbidities

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Step 7-

Environmental Factors:

Action -

Advice on allergens avoidance

Animals outside the home (cats, dogs, hamsters)

Dust Mites: Allergy Waterproof Cases

Damp cloth and vacuum

Home Humidity <50%

No carpets in the bedroom

Washing with hot water weekly

Pollens: Close windows in time of pollination

Snuff: Avoid smoking and passive exposure

Fungi: Remove mildew stains on the walls

Avoid wood stoves, smoke, air fresheners, etc..

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Classification of severity of asthma exacerbations.

Symptoms  Speech

Mild

Breathlessness With activity Sentences

Moderate

With talking Phrases

Severe

At rest Words

Impending Respiratory Failure

At rest Mute

    

 

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Mild Moderate Severe Impending Respiratory Failure

Signs

 

Body position

Able to recline Prefers sitting Unable to recline Unable to recline

  

Respiratory rate

Increased

Increased

Often > 30/min > 30/min  

 

Use of accessory respiratory muscles

Usually not Commonly Usually Paradoxical

thoracoabdominal

movement

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Pulsus

paradoxus

(mm Hg) Mental status

Mild < 10 May

beagitated

Moderate 10–25 Usually agitated Sever often > 25 Usually agitate

Impending Often absent   Confused or drowsy

 

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Mild Moderate Severe Impending Respiratory Failure

 

 

Breath sounds Heart rate (beats/min)

Moderate wheezing at mid- to end-expiration < 100

Loud wheezes throughout expiration 100-120

Loud inspiratory and expiratory wheezes > 120

Little air movement without wheezes

Relativebradycardia

 

   

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Mild Moderate Severe Impending Respiratory Failure

Functional assessment

   

 PEF (% predicted or personal best

)

> 80 50–80 < 50 or response to therapy lasts < 2 hours < 50   

SaO

2

(%, room air)

> 95 91–95 < 91 < 91  

 Pa O

2

(mm Hg, room air)

  Normal > 60 < 60 < 60   

Pa CO

2

(mm Hg)

< 42 < 42 42 42

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Immediate treatment of patients with acute severe asthma.

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Indications for assisted ventilation in acute severe asthma

Coma

Respiratory arrest

Deterioration of arterial blood gas tensions despite optimal therapy

Pa

O

2

< 8

kPa

(60 mmHg) and falling

Pa

CO

2

> 6

kPa

(45 mmHg) and rising

pH low and falling (H

+

high and rising)

Exhaustion, confusion, drowsiness

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Symbicort

® efficacy enhanced by

Turbuhaler

Device

36

%

Diskus

12%

Fine particles lead to higher lung deposition that leads to higher improvement in lung function

1-5

1.

Borgstrom

L et al.,

Int

J

Clin

Pract

, 2005, 59, 12, 1488-1495 2.

Thorsson

L et al.,

Int

Journal of Pharmaceutics 168 (1998) 119-127

3.

Usmani

O, AM J

Resp

and Critical Care Medicine,

vol

172 2005; 1497-1504 4.

Selroos

et al., Treat

Resp

Med 2006; 5 (

suppl

48): 584S.

5.

Selroos

et al., Treat

Resp

Med 2006; 5 (5): 305-315

Device Comparison for lung deposition

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Symbicort®… The only combination treatment offering flexibility in prescription

1

1 inhalation

every morning

Extra doses

when needed

1 inhalation

every evening

1.

Symbicort

Turbuhaler

160/4.5 mg/dose SX Leaflet text

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Complication

1-Pnemothorax.

2-exacerbation.

3-bronchiectasis.

4-Respiratory failure.

5-Druge side effects.

Prognosis

Control can achieved as a chronic disease ,death

is uncommon.

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Discussion and questions

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Many thanks

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