Bronchial Asthma

BRONCHIAL ASTHMA
It is a chronic inflammatory disorder characterised by paroxysmal and reversible

airway obstruction
Risk factors HOPEGAM

• genetic predisposition
• Race ( Africa - America )
• Personal or family history of atopy ( immune reactions characterised by over
production of igE)
• Obesity
• Prematurity
• Low birth weight
• Environmental factors : air pollution, house dust mite, pollen, smoking ( active or
passive, pets, weather( cold air)
• Viral infections ( human rhinovirus - is most implicated here)
• Maternal smoking
HMPV - second most common
cause of bronchiolitis
Trigger factors
• Viral upper respiratory tract infections

• Allergies
◦ Pollen
◦ Dust mite
◦ Pet
◦ Food ( implicated in legume diet )
◦ Mold
◦ Strong perfumes
◦ Chemicals: paint, aerosols
• Exercise
• Emotional stress/ anxiety
• Cold air
• Altitude
Pathophysiology
• Presents of the risk factors. Ie. genetic predisposition, atopy and environmental
factors lead to the 3 main mechanisms that cause asthma. These are
• bronchial hyperresponsiveness : exaggerated twitching of the airway in response

to the various stimuli
• mucosa inflammation : mucosal edema, excessive mucus production( forming

mucosal plugs in the bronchi)
• narrowing of the bronchi : bronchoconstriction
Clinical presentation (W BCC)

• W - wheezing ( usually expiratory but can be inspiratory in severe )
• B - breathlessness
• C - cough ( usually dry : mucus forms ) diurnal in nature ( worse at night and in
the morning )
• C - chest tightness Anytime that there are
persistent recurrent wheezes,
suspect asthma
Wheeze - a high pitched whistling sound heard due to the the passage of turbulent
airflow through a narrow airway
Asthma can cause a pseudo hepatomegaly , this is cause the hyper inflated lungs will
push the liver downwards and hence the liver can be palpated more than 2 cm
below the costal margin
Physical exam
• signs of respiratory distess
◦ Use of accessory respiratory muscles : SIP
◦ Nasal flaring
◦ Suprasternal recession / retraction / Indrawing
◦ Intracoastal recession
◦ tahcypnea
◦ Tachycardia Pigeon chest- pectus
carinatum
• Wheezing
• Harrison’s groove/ sulcus - flaring of the ribs pulling on the diaphragm
PALPATION
• palpable liver below the right coastal margin
• Reduced chest expansion
PERCUSSION
• hyperresonance due to the hyper inflated lung
AUSCULTATION
• Reduced air entry
• Reduced breath sounds
• Adventitious Lung sounds : Fine end crackles, ronchi)
Investigations
• FBC : wbcs ( eosinophils )
• Skin prick test : r/o atopy
• PEFr : in children > 5 years , because by then their respiratory muscles are fully
developed and capable of the normal function
◦ Spirometry : tiffeneau index/ ratio ie FEV1 / FVC
• Chest x ray : hyperinflated lungs ( radiolucency of lung fields )
Vital capacity - the maximum amount of air that can be
expired after deep inspiration
normal PEFr = 60-80 percent

Classification of asthma based on the severity ( frequency of symptoms )
Parameters Mild intermittent Mild persistent Moderate persistent Severe persistent
< 2 days/ week >2 days per week Daily Several times/
1.day time symptoms frequently during
but not daily
the day
> 2 nights(3-4) per >1 time / week but Every night ( 7x per
2. Night time symptoms <2 nights / month
month not nightly week)
3. Symptom control < 2 days per week > 2 days per week Several times per
with SABA but not daily Daily day
4. Limitation with None Mild Some degree Severe

normal activity
Classification of asthma based on the severity of attack

Moderate acute asthma Severe acute asthma Life threatening acute asthma
• PEFr: 50-60 percent of the • PEFr : 33-50% of the predicted • <33% of the predicted
predicted value value value
• SpO2 : > 92% • Tachypnea (RR> 30cpm in children • cyanosis

>5 years ), RR>50cpm (2-5 years)
• tachycardia ( hr > 120bpm in • bradycardia

children > 5 years , hr >130bpm in
children 2-5 years)
• cannot complete a sentence in • hypotension

one full breath
• SPO2 < 92% • silent chest
Treatment
• SABA - short acting beta 2 adrenergic agonist, aka the relievers ( smooth muscle
relaxants)
◦ salbutamol, terbutaline
• anticholenergic drug eg ipratropium bromide

• inhaled Corticosteroids ( preventives)- budesonide, fluticasone, beclomethasone,
• LABA : long acting beta 2 adrenergic agonists - eg salmeterol, formoterol
• oral corticosteroids eg prednisolone
• methylxanthines eg. Theophylline
• leukotriene receptor antagonists eg. Montelukast
• anti igE injections - eg. Omalizumab
An imbalance b/n t1 and t2 lymphocytes can trigger asthma due to the over
production of interlukines and tnf alpha causing an inflammatory process
Combination therapy
• come in the form of metered dose inhalers.
◦ Symbicort ( smart therapy) : budesonide + formoterol
◦ Seretide : fluticasone + salmeterol
• salbutamol - Prorenata ( as needed ) 2-4 puffs but can be used up to 10 puffs. In

20-30 minutes
Management of severe acute asthma ( O- SHI T)

• admit
• 100 percent humidified oxygen via nasal prongs or face mask
• Nebulised salbutamol ( 2.5mg when <5 years or 5mg when > 5 years )
• Assess within 20-30 minutes, if symptoms still persist
• Nebulise again
• Assess within 20-30 mins, if symptoms still persist
• Add ipratropium bromide ( on the third attempt )( 125mg <5 yrs, 250mg >5 yrs)
• Reassess within 20-30mins, if symptoms still persist
• Give IV hydrocortisone ( 4mls/kg)
• Reassess, If symptoms still persist
• Give IV aminophylline on consultation with senior colleague
• Give IV MgSO4
• Intubate and send to intensive care unit
• on discharge, put on salbutamol ( reliever) + oral prednisolone( preventer) for at

least 3 days
Inhaler advice
• 2-4 puffs before any strenuous activity
Step approach to the treatment of chronic asthma

• Step 1
◦ Give short acting beta 2 adrenergic agonist
◦ ipratropium bromide if < 5 yrs
• Step 2- add inhaled corticosteroid if they use more than 3 inhalations per week, if
less than 5 years add oral leukotriene receptor
• Step 3- if more than years add LABA, if working, continue, if not working
adequately move to Step 4, if not at all add leukotriene receptor antagonist. If
less than 5 year, give oral leukotriene receptor antagonist . If less than 2 years,
refer
• Step 4- if more than 5 years, Increase inhaled steroid to maximum recommended

dose or refer if less than 5 years
◦ If less than 5, refer to respiratory pediatrician
• Step 5- oral prednisolone and refer to specialist

Simplified version
• step 1 - SABA
• step 2 - SABA + corticosteroids
• Step 3- SABA + corticosteroids + LABA
Differentials O
• bronchiolitis O
• Foreign body aspiration
• Croup
f
• COPD ( adults )
• Congestive cardiac failure
• Cystic fibrosis
• Gastroesophageal reflux disease
• Vocal cord paralysis
• Bronchiectasis
Complications T
m
i
• pneumothorax
• Respiratory failure
• Cardiac arrest
g
• Pneumomediastinium
Dear wepiah
EEEani a
You are the light of my world You are the sweetestperson

I have ever met I love
you with my whole being Cheers to
more years together Caint wait for us to become Doctors
n
Ei potage
B
tBy we aa a
man

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BRONCHIAL ASTHMA

It is a chronic inflammatory disorder characterised by paroxysmal and reversible

Risk factors HOPEGAM

• Viral upper respiratory tract infections

• bronchial hyperresponsiveness : exaggerated twitching of the airway in response

• mucosa inflammation : mucosal edema, excessive mucus production( forming

• narrowing of the bronchi : bronchoconstriction

Clinical presentation (W BCC)

• Harrison’s groove/ sulcus - flaring of the ribs pulling on the diaphragm

normal PEFr = 60-80 percent

4. Limitation with None Mild Some degree Severe

Classification of asthma based on the severity of attack

• SpO2 : > 92% • Tachypnea (RR> 30cpm in children • cyanosis

• tachycardia ( hr > 120bpm in • bradycardia

• cannot complete a sentence in • hypotension

• SPO2 < 92% • silent chest

• anticholenergic drug eg ipratropium bromide

• oral corticosteroids eg prednisolone

• methylxanthines eg. Theophylline

• leukotriene receptor antagonists eg. Montelukast

• anti igE injections - eg. Omalizumab

• salbutamol - Prorenata ( as needed ) 2-4 puffs but can be used up to 10 puffs. In

Management of severe acute asthma ( O- SHI T)

• on discharge, put on salbutamol ( reliever) + oral prednisolone( preventer) for at

Step approach to the treatment of chronic asthma

• Step 4- if more than 5 years, Increase inhaled steroid to maximum recommended

• Step 5- oral prednisolone and refer to specialist

You are the light of my world You are the sweetestperson

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