Asthma

Introduction
Asthma is a chronic
respiratory disorder that’s
characterized by
inflammation and
narrowing of the airways
leading to have respiratory
symptoms, such as
breathlessness, wheezing,
chest tightness, and
coughing, that vary in
intensity and time.
Pathophysiology of Asthma

01 Inflamation
Lead to increase thickness of the
smooth muscles and mucus
secretion

02 Narrowing
Due to hyper-responsiveness
causing narrowing, airways hyper-
reactivity and airflow limitations
 Types of Asthma
According to immune response, Asthma can be driven by two
types:
01 02
Th2 high
Th2 low Asthma
Asthma Typically involves
non-allergic
Characterised by an mechanisms, non-
overproduction of IgE dependent,
cytokines like IL-4, often triggered by
IL-5, and IL-13, factors unrelated
which promotes IgE to immune
production and allergens, such as
allergic respiratory
infections,
inflammation.
it is less responsive
to traditional
therapies.
 Asthma during pregnancy
● in the second trimester,
● asthma pathophysiology can be influenced by
● mechanical and physiological changes
● such as hormonal changes, particularly progesterone
can increase airway responsiveness and make the airway
way more susceptible to viral infections ( which are a
common asthma trigger).
● pregnancy increase the overall respiratory demand due
to higher oxygen needs, and this may also lead to
exacerbations.

● Untreated asthma during pregnancy can lead to poor

maternal and fetal outcomes, including pre-eclampsia, pre-
term delivery, and low birth weight.
 Question
What are the main characteristics of
asthma, its types, and the effects of
pregnancy on asthma management?

a) Asthma is primarily a genetic condition with no environmental

triggers, characterized by permanent airway narrowing and
constant symptoms. Pregnancy has no impact on asthma
management.

b) Asthma involves airway inflammation and hyper-

responsiveness, with types driven by Th2 high (allergic) and
Th2 low (non-allergic) mechanisms. Pregnancy can increase
airway responsiveness and exacerbate symptoms.

c) Asthma only affects people in childhood, is always triggered

by allergens, and is not affected by pregnancy.

d) Asthma is a temporary respiratory infection with symptoms

Diagnosis of
asthma
How is asthma
diagnosed?

1. History of characteristic symptom patterns and

evidence of variable expiratory airflow limitation.

2. Document the evidence before starting inhaled

corticosteroid (ICS) containing treatment to prevent
reduction variability of both symptoms and lung
function test.

3. confirming additional or alternative strategies ,

including patients who already on ICS- containing
treatment or the elderly patient presenting with
cough as same as asthmatic patient .
SYMPTOMS OF THE DISEASE

1. Shortness of

Breath

2. Wheezing

3.Coughing

4. Chest

Tightness
 Lung function
test
Lung function tests, also known as pulmonary
function tests (PFTs), are a series of non-
invasive assessments that measure how well the
lungs are working.

It is crucial for :
1. Diagnosis
2. Monitoring
3. Management
 Spirometry parameters
• Forced vital capacity (FVC) (liters)
the maximum amount of air a person can forcefully
exhale after taking a deep breath.

• Forced expiratory volume in one second ( FEV1)

indicates the amount of air a person can forcefully exhale
in the first second of a breath.

• FEV1/FVC Ratio:
This ratio helps differentiate between obstructive and
restrictive airway diseases.
 Break down of obstructive and
reversibility aspects in asthma
• Pre-and post bronchodilator testing :
defined as improvement as an increase of 12%
or more in FEV1 after administration of a
bronchodilator indicates reversibility

Reversibility
• Means that airflow
limitation can improve
significantly with
bronchodilator
medications (albuterol)
 Peak expiratory flow
• Done by measuring PEF twice daily (morning and evening )
over a period of 2-3 weeks and noting the highest value

• Normal PEF values vary based on factors like age, sex,

height, and ethnicity.

*Green Zone*: 80% to 100% of personal best – Good control,

no symptoms.

*Yellow Zone*: 50% to 79% of personal best – Caution; may

need to take medication or consult a healthcare provider.

*Red Zone*: Below 50% of personal best – Medical alert;

immediate action is required, such as using a rescue inhaler or
seeking medical attention
Note :

a decrease in FEV1 or PEF during a

respiratory infection, while commonly
seen in asthma, does not necessarily
indicate the person has asthma, as it may
also be seen in otherwise healthy
individuals or those with COPD.
According to the information listed above regarding adults and children,
There are key a point regarding the diagnosis of asthma in pregnant
women includes:

• Pregnant women and women planning a pregnancy should be asked whether they
have asthma, so that appropriate advice about asthma management and
medications can be given

• If the clinical history is consistent with asthma, and other diagnoses appear
unlikely, but the diagnosis of asthma is not confirmed on initial bronchodilator
responsiveness testing the patient should be managed as having asthma with ICS-
containing treatment.

• During pregnancy, bronchial provocation testing is contraindicated, and it is not

advisable to step down ICS-containing treatment.
 Question
Which of the following statements regarding the diagnosis of
asthma is least accurate ?

A. Asthma can be diagnosed based on a combination of

clinical history, physical examination, and lung function tests.

B. A positive bronchoprovocation test indicates hyperactivity

of the airways and supports an asthma diagnosis.

C. The presence of eosinophils in the sputum is a definitive

marker for asthma and eliminates the need for further
testing.

D. Diurnal variation in peak expiratory flow rates can be

indicative of asthma and is often used in monitoring the
 Pharmacological
1.B2 agonist
treatment
•Short acting Beta receptor (SABA)
-Selective agonism of B2 adrenergic receptor which bind and relax the
bronchial and vascular smooth muscle lead to rapid bronchodilation. (4H).
-Ex: Salbutamol (Albuterol), Terbutaline.
-S.E: Tachycardia, Hyperglycemia, Hypokalaemia, Hypomagnesia, tremor
specific in children.

•Long acting Beta receptor (SABA)

-Selective agonism of B2 adrenergic receptor which bind and relax the
bronchial and vascular smooth muscle lead to prolong bronchodilation.
(12H).
-Ex: Salmetrol, formoterol.
-S.E: Tachycardia, Hyperglycemia, Hypokalaemia, Hypomagnesia, tremor
specific in children.
 •Ultra long acting Beta receptor (ULABA)
-work by activating B2 adrenergic receptor in the bronchial smooth muscle
lead to more prolong bronchodilation (>24H)
-Ex: Indacterol, Olodaterol , Vilanterol .
S.E: Tachycardia, Palpitation, Nervousness, Hypokalemia, headache.
2.Anticholinergic Drug
-They block muscarinic acetylcholine receptor (mainly M3)
located on bronchial smooth muscle, decrease
bronchoconstriction, and relax smooth muscle.
-Ex: Ipratropium bromide , Oxitropium bromide
-S.E: Urinary retention , Blurred vision , Tachycardia
3.Methylxanthen
-They block adenosine receptor (A1) , which enhance
bronchodilation and improve airflow .
-Ex: theophylline (tab), Aminophylline (Inj)
-S.E: CNS stimulation, palpitation , Hypokalaemia,
tachycardia, headache , Arrhythmia
4.Corticosteroids (anti-inflammatory)
-B cell They inhibition of antibody production, leading to decrease
immunoglobulin’s .
-T cell inhibit activation and proliferation of T cell , and production of
cytokines
-Mast cell reduce the activation and degranulation of the cell, leading to
decrease release of histamine or other inflammatory mediators.
-Ex: Oral : Prednisolone , Dexamethasone
IV : Hydrocortisone
Inhaler: Budeosonide , Fluniosolide
-S.E: Adrenal suppression , Oral thrust (white patches) like candida ,
Dysphonia , Hypokalemia , caught , Sore throat .
-Advice: Rinse their mouth after inhaling
5.Leukotriene antagonist (prophylactic) :
•Oral antagonist
-Inhibiting the effect of leukotriene receptors especially LD4, which help to
reduce inflammation and bronchodilation.
- Ex: Zafiralukast, Montelukast
•Inhibitor
-Inhibit the 5-lipoxygenase enzyme, which it’s crucial in the biosynthesis of
leukotriene from arachchidonic acid.
-Ex: Zileuton
-S.E: Elevation in serum hepatic enzyme, headache, Dyspepsia, Eosinophilia
vacuities
6.Mast cell stabilizer (prophylactic)
-Mast cell release inflammatory mediators like histamine when activated.
This activation require influx of Ca+.
-Mast cell stabilizer prevent the entry of influx, which is crucial for the
degranulation.
-Ex. Cromolyn sodium, Nedocromil sodium , ketotifen
-S.E: irritation of the pharynx and larynx, mild better taste
7.Omalizimab (prophylactic)
-Its selective bind to (IgE)
- Omalizimab inhibit the binding of igE to mast cell which reduce
the activation and degranulation of the cell .
-S.E: Shortness of breathing , tiredness , chest pain , caught
8.Mepolizumab , Reslizumab
-Specifically target &bind to IL-5
-Its inhibiting IL-5 , leading to decrease eosinophil level , which
reduce inflammation.
-Mepolizumab (SC) , Reslizumab(IV).
-S.E: headache , injection site reaction , breathing problem ,
fatigue .
 Quest
A 50-year-old patient with a history of asthma is being treated
ion
with a combination of long-acting beta-agonists (LABAs) and
inhaled corticosteroids. During a follow-up visit, the patient
reports experiencing increased heart rate and mild hand
tremors. Which of the following medications is most likely
responsible for these side effects?

A) Ipratropium bromide
B) Salmeterol
C) Theophylline
D) Budesonide
Non-pharmacological treatment
• Avoidance of tobacco smoke
exposure
• Avoid medications that may worsen
asthma like NSAIDs or beta-
blockers
• Remediation of dampness or mold
in homes
• Stay away from chemicals and
perfumes
 Management of asthma
Goals of asthma management:
1. Symptom control: to achieve good control of symptoms and maintain normal
activity levels.

2. Risk reduction: to minimize future risk of asthma-related mortality,

exacerbations, persistent airflow limitation and side-effects of treatment
 Assessment
1-Assess symptom control over the last 4
weeks.

2-Assess risk factors for poor outcomes.

 Risk factor for exacerbation
 Risk factor for developing persistent airflow
limitation
 Risk factor for medication side effects
 Treatment
Adjustment
Before treatment adjustment ,it is crucial to
understanding strategy of treatment based
on the patient's age and disease severity.

• Strategy for treatment adult asthma ≥12years

• Strategy for treatment children asthma 6-
11years

• Strategy for treatment pregnant asthma

 Strategy of
treating Asthma
in adult
≥12years
 Step 1
Intermittent

Step 2
Intermittent

Step 3
Persistent
(mild)

Step 4
Persistent
(moderate)

Step 5
Persistent
(severe)
 Question
A 35-year-old man with asthma reports frequent symptoms nearly
every day and wakes up at night with breathing difficulties at least
twice a week. His lung function tests show impaired airflow. His
current treatment includes a low-dose ICS-formoterol as-needed, but
his symptoms persist.

Which treatment step would be most appropriate to help control his

symptoms?

a) Continue with low-dose ICS-formoterol as

needed
b) Switch to low-dose maintenance ICS-
formoterol (MART)
c) Increase to medium-dose maintenance ICS-
 Strategy of
treating Asthma
in children 6-11
years
 Question
A 9-year-old child with asthma reports daily
symptoms and wakes up at night with
breathing difficulties about once a week. The
child’s lung function tests are normal.
Currently, they are using a low-dose ICS as
needed and a SABA for quick relief, but
symptoms persist.

Which step would be the most appropriate for

managing this child’s asthma?

a) Continue with low-dose ICS as needed, plus

SABA for quick relief
b) Switch to daily low-dose ICS, plus SABA as
needed
Strategy of treating Asthma in
pregnancy
1. Inhaled Corticosteroids (ICS):
ICS is the mainstay of asthma treatment during pregnancy. Stopping ICS is not
recommended, as it increases the risk of exacerbations.

2. Short-Acting Beta-Agonists (SABA):

SABAs are safe for relief of acute symptoms and can be used as needed.

3. Long-Acting Beta-Agonists (LABA):

LABAs may be considered in combination with ICS for patients whose symptoms are
not well-controlled on ICS alone.
(leukotriene receptor antagonists, and theophylline are alternative options)

4. Oral Corticosteroids:
Should be used only for severe asthma and managed carefully, as prolonged use may
carry additional risks during pregnancy.
 Strategy of treating Asthma in
pregnancy
Allergic rhinitis, often associated with
asthma

1.Intranasal corticosteroids are the most

effective and safest treatment option

2.First-generation antihistamines
 Monitoring
1- Regular monitoring :
After initiating treatment, follow-up
appointments should be scheduled 1-3
months later

Subsequent reviews can be spaced out to

every 3-12 months for well-controlled
patients.

2- pregnant women:
more frequent monitoring, every 4-6 weeks,
is recommended due to the fluctuating
hormonal changes and increased risk of
exacerbations. Following an exacerbation, a
review visit within one week is crucial to
 Question
A 28-year-old pregnant woman in her second trimester
comes to the clinic for asthma management. She mentions
occasional wheezing and shortness of breath, especially at
night. Which of the following treatments is both safe and
recommended for her to prevent asthma exacerbations
during
pregnancy?

a) Immunotherapy
b) Oral corticosteroids
c) Inhaled corticosteroids
d) First-generation antihistamines