COURSE TITLE: ADVANCED CLINICAL PHARMACY-1

COURSE INCHARGE: MISS QUDSIA BASRI

COURSE NO: 711-T
ASSIGNMENT TOPIC: REVIEW ARTICLE ON ASTHMA
SUBMITTED BY: GROUP # 06

GROUP MEMBERS:
 ALISHA FAROOQ
 ABEEHA ZARFAR
 JAWERIA SHUJAAT

ASTHMA
INTRODUCTION:
A common condition, asthma can range in intensity from a very slight, infrequent wheeze to an
abrupt, life-threatening airway closure. It typically first manifests in children and is linked to
other atopy symptoms including eczema and hay fever.
Children who have asthma are more likely to require multiple hospital stays, which raises the
expense of healthcare. [1] [2] [3]
The main characteristic, which can be brought on by a variety of circumstances, is airway hyper
responsiveness.
Asthma has a significant death rate if not treated right away. [4]

ETIOLOGY:
There are many different forms of asthma and a wide spectrum of diverse phenotypes.
The known risk factors for asthma include a genetic predisposition, in particular a personal or
family history of atopy (predisposition to allergies, typically manifested as eczema, hay fever and
asthma). [5] [6] Exposure to other inflammatory gases or particulates, such as tobacco smoke, is
also linked to asthma.
It is generally agreed that asthma is a multifactorial pathology that is influenced by both genetics
and environmental exposure. The etiology is complex and still not fully understood, particularly
in terms of predicting which children with paediatric asthma will continue to have asthma as
adults (up to 40% of children have a wheeze, only 1% of adults have asthma).
Common triggers for asthma are:
• Viral respiratory tract infections
• Exercise
• Gastroesophageal reflux disease
• Chronic sinusitis
• Environmental allergens
• Use of aspirin, beta-blockers
• Tobacco smoke
• Insects, plants, chemical fumes
• Obesity
• Environmental elements or stress

EPIDEMIOLOGY:
Around 15%-20% of people in affluent countries and 2%-4% of people in less developed nations
suffer with asthma, which is a prevalent pathology. Children are far more likely to experience it.
Regardless of lung function testing, up to 40% of children will experience wheezing at some
point, and if it can be treated with beta-2 agonists, it is classified as asthma. [7] [8]
Asthma is more prevalent in people with certain environmental exposures because it is linked to
exposure to cigarette smoke and inhaled particles.
Up until puberty, when the male to female ratio changes to 1:1, boys are more likely than girls to
have asthma in childhood. Females are more likely to develop asthma after puberty, and after the
age of 40, most adult-onset instances of asthma are in females.
Due to decreased lung function and airway reactivity, asthma prevalence is higher in older
individuals. About 66% of all cases of asthma are identified before the age of 18 years. [9]
In early adulthood, the severity of or complete cessation of asthma symptoms occurs in about
50% of asthmatic children. [10]
PATHOPHYSIOLOGY:
Acute, fully treatable airway inflammation characterises asthma, which frequently develops after
exposure to an environmental cause. The pathogenic process begins with the inhalation of an
allergen or an irritant, such as cold air, which causes bronchial hypersensitivity and, as a result,
causes the airways to become inflamed and produce more mucus. As a result, there is a notable
rise in airway resistance, which is most noticeable during expiration.
When the following factors combine, airway blockage occurs:
 infiltration of inflammatory cells.
 mucous hypersecretion with the development of mucus plugs.
 contraction of smooth muscles.
 These permanent modifications could eventually become irreversible owing to
 thickening of the basement membrane, collagen buildup, and desquamation of the
epithelium.
 Chronic diseases that cause smooth muscle hypertrophy and hyperplasia cause airway
remodelling.
If asthma is not treated right away, it could get worse because the formation of mucus keeps the
inhaled medication from getting to the mucosa. The swelling from the inflammation also gets
worse. Beta-2 agonists (such as salbutamol, salmeterol, and albuterol) and muscarinic receptor
antagonists (such as ipratropium bromide) can help resolve this process (complete resolution is
necessary in asthma, but in practice, this is not checked or tested). These medications work to
reduce inflammation and relax the bronchial musculature while also decreasing mucus
production (11).
TOXICIKINETICS:
As the absorption and systemic side effects of the beta-2 agonists must be watched for, the only
important toxicokinetic in asthma relates to its management. Salbutamol and albuterol typically
leave the body in 2 to 4 hours, salmeterol in 18 to 24 hours, and clenbuterol, which is no longer
used to treat asthma, in 48 to 72 hours.
Tachycardia, flushing, sweating, and other symptoms of sympathetic system hyperactivity are
adverse effects of beta-2 agonists. Additionally, iatrogenic hypokalemia is a possibility that needs
to be watched out for.

HISTORY AND PHYSICAL:

Typically, patients will describe a cough or wheeze that was made worse by a cold, exercise, or
allergies. There is frequently a diurnal fluctuation, with nighttime symptoms being more severe.
Patients may provide a history of additional atopy conditions such eczema and hay fever. Acute
exacerbations might sometimes be accompanied by a slight amount of chest pain. Many
asthmatics experience nighttime coughing episodes yet present normally throughout the day.
The results of the physical exam will depend on whether the patient is going through an acute
exacerbation right now.
Due to the usage of salbutamol, there may be a moderate tachycardia and a fine tremor in the
hands during an acute exacerbation. Patients who have respiratory discomfort frequently lean
forward to widen their airways. A bilateral, expiratory wheeze can be audible on auscultation. As
the lungs cannot take in or expel air, asthma that is life-threatening may cause the chest to be
quiet and show signs of systemic hypoxia.
Children who are about to pass out could seem sleepy, unresponsive, cyanotic, or disoriented.
The absence of wheezing and the occurrence of bradycardia are signs of significant respiratory
muscle exhaustion.
Systemic steroids and beta 2 agonist nebulization are ineffective treatments for a specific kind of
asthma called life-threatening asthma.Early detection is essential since it could result in a high
death rate. On examination, the following distinctive observations were made about it.
 Peak expiratory flow 33% of best-ever value
 Saturation of oxygen less than 92%
 Carbon dioxide’s typical partial pressure
 Discreet chest cancer
 Weak effort with breathing
 Bradycardia
 Arrhythmias
 Hypotension
 Coma, confusion
 Exhaustion
The partial pressure of carbon dioxide is increased in asthma that is nearly lethal, or mechanical
ventilation is necessary with elevated inflation pressures.
EVALUATION
1. BEDSIDE:
Assessing the severity of an asthma attack or monitoring for deterioration can be made
easier with pulse oximetry. A falling pO2 on pulse oximetry is a late finding, indicating a
severely ill or peri-arrest patient, due to the physiological reserve of many patients and
the pulse oximetry lag.

Asthma can also be evaluated using peak flow measurements, which should always be
compared to a nomogram and the individual patient's normal baseline function. A peak
 flow measurement that is recorded as a certain percentage of the expected peak flow
corresponds to the various severity levels of acute asthma attacks.

2. LABORATORY:
Urea and electrolytes (kidney function) should be taken if the patient takes a lot of
salbutamol or takes it again. One of salbutamol's side effects is that it temporarily moves
potassium into the intracellular space, which can cause temporary, iatrogenic
hypokalemia. Although it is common, eosinophilia is not specific to asthma. Eosinophil
counts in the sputum may help direct treatment, according to recent research.
Additionally, arterial blood gas may reveal respiratory acidosis and hypoxemia in some
patients, as well as an elevation of serum IgE. Periostin may be a marker for asthma,
according to studies, but its clinical function is still unclear. Sinus tachycardia can be the
result of asthma, albuterol, or theophylline, as shown by an electrocardiogram (ECG).
Imaging A chest x-ray is an important test, especially for patients who have a history of
being at risk for an infection or foreign body. Patients with persistent symptoms who do
not respond to therapy undergo a chest CT scan.

3. SPECIAL TEST:
The preferred method of diagnosis is spirometry, which will reveal an obstructive pattern
that can be partially or completely resolved with salbutamol. Spirometry ought to be
finished before treatment to decide the seriousness of the problem. A decrease in the ratio
of FEV1 to FVC is a sign of airway obstruction that can be cleared with treatment. The
patient is administered inhaled short-acting beta 2 agonists for reversibility testing, and
the spirometry test is then repeated. If the FEV1 improves by 200 milliliters or 12 percent
from the previous value, this indicates reversibility and can be used as a diagnostic for
bronchial asthma. Today, peak expiratory flow measurement is common and allows one
to record therapy response. One of the test's limitations is that it is effort-dependent.
TREATMENT:
CONSERVATIVE MEASURES:
The patient should be calmed in order to induce relaxation, moved outside or away from the
likely allergen source, and cooled. Although it is sometimes done to get rid of allergens, taking
off one's clothes and washing one's face and mouth are not proven to be effective.[12][13][14]
Keeping control of one's environment is essential to avoiding recurring attacks. Avoiding
allergens can significantly enhance quality of life. This means avoiding pollen, animals, tobacco,
dust mites, and animals.
Improved control is achieved when obese asthmatics lose weight.
Immunotherapy with allergens is still controversial. The method is prohibitively expensive, and
large studies have not demonstrated any significant benefits.
Patients who have a positive skin test and have moderate to severe asthma should be treated with
monoclonal antibody therapy. The treatment may decrease histamine production by lowering IgE
levels. However, the injections are expensive.
Bronchial thermoplasty is a relatively new procedure that narrows the airways by delivering
thermal energy to the wall of the airway. It can cut down on emergency visits and days off from
school, according to several studies.
MEDICAL:
The treatment of chronic asthma consists of five steps:
Step 1: Depending on how well the patient responds to treatment, the level of treatment is
increased or decreased [15]. Formoterol and low-dose inhaled corticosteroids are the preferred
controller when needed.
Step 2: As needed, short-acting beta 2 agonists and daily low dose inhaled corticosteroids are the
preferred controllers.
Step 3: Low-dose inhaled corticosteroids, long-acting beta 2 agonists, and short-acting beta 2
agonists are the preferred controllers.
Step 4: A medium-dose inhaled corticosteroid, a long-acting beta 2 agonist, and short-acting beta
2 agonists are the preferred controllers.
Step 5: Corticosteroid inhaled at a high dose, a beta 2 agonist with a long half-life, and an anti-
IgE/muscarinic antagonist with a long half-life.
SURGERY:
The treatment of typical asthma does not involve surgery.
LONG TERM MANAGEMENT:
Weight loss, quitting smoking, changing jobs, and self-monitoring are all important for reducing
the number of acute attacks and preventing disease progression.

REFERENCES:
1. Lee J,McDonald C, Review: Immunotherapy improves some symptoms and reduces long-term
medication use in mild to moderate asthma. Annals of internal medicine. 2018 Aug 21
2. Tesfaye ZT,Gebreselase NT,Horsa BA, Appropriateness of chronic asthma management and medication
adherence in patients visiting ambulatory clinic of Gondar University Hospital: a cross-sectional study.
The World Allergy Organization journal. 2018
3. Salo PM,Cohn RD,Zeldin DC, Bedroom Allergen Exposure Beyond House Dust Mites. Current allergy
and asthma reports. 2018 Aug 20
4.Scirica CV,Celedón JC, Genetics of asthma: potential implications for reducing asthma disparities.
Chest. 2007 Nov
5.Piloni D,Tirelli C,Domenica RD,Conio V,Grosso A,Ronzoni V,Antonacci F,Totaro P,Corsico AG,
Asthma-like symptoms: is it always a pulmonary issue? Multidisciplinary respiratory medicine. 2018
6. Aggarwal B,Mulgirigama A,Berend N, Exercise-induced bronchoconstriction: prevalence,
pathophysiology, patient impact, diagnosis and management. NPJ primary care respiratory medicine.
2018 Aug 14
7. Yii AC,Soh AZ,Chee CBE,Wang YT,Yuan JM,Koh WP, Asthma, sinonasal disease, and the risk of
active tuberculosis. The journal of allergy and clinical immunology. In practice. 2018 Aug 18
8. D'Amato M,Molino A,Calabrese G,Cecchi L,Annesi-Maesano I,D'Amato G, The impact of cold on the
respiratory tract and its consequences to respiratory health. Clinical and translational allergy. 2018
9. Burrows B,Barbee RA,Cline MG,Knudson RJ,Lebowitz MD, Characteristics of asthma among elderly
adults in a sample of the general population. Chest. 1991 Oct
10. Martin AJ,Landau LI,Phelan PD, Lung function in young adults who had asthma in childhood. The
American review of respiratory disease. 1980 Oct
11.Southworth T,Kaur M,Hodgson L,Facchinetti F,Villetti G,Civelli M,Singh D, Anti-inflammatory effects of the
phosphodiesterase type 4 inhibitor CHF6001 on bronchoalveolar lavage lymphocytes from asthma patients. Cytokine.
2018 Jun 19 [PubMed PMID: 29934047]
12. Gosens R,Gross N, The mode of action of anticholinergics in asthma. The European respiratory journal. 2018 Oct
[PubMed PMID: 30115613]
13. Almadhoun K,Sharma S, Bronchodilators null. 2018 Jan [PubMed PMID: 30085570]

14. Jilani TN,Sharma S, Theophylline null. 2018 Jan [PubMed PMID: 30085566]
15. Rajan S,Gogtay NJ,Konwar M,Thatte UM, The global initiative for asthma guidelines (2019): change in the
recommendation for the management of mild asthma based on the SYGMA-2 trial - A critical appraisal. Lung India :
official organ of Indian Chest Society. 2020 Mar-Apr [PubMed PMID: 32108606]