Asthma chapter 8
Page 2: Introduction to Asthma
Asthma is a complex genetic disorder influenced by multiple genes.
It is multifactorial, involving various environmental factors affecting its characteristics.
Chronic respiratory disorder: Causes inflammatory changes and bronchoconstriction in the airways.
Severity varies significantly among individuals, with episodes of exacerbation alternating with symptom-free intervals.
Asthma prevalence has increased over recent decades, leading to significant disability, medical expenses, and preventable deaths.
Food, lifestyle, or what has caused increase in asthma?
Page 3: The Role of the Asthma Educator
Introduction of the "Asthma Educator" role for respiratory therapists (RT).
Goal: Ensure patients and families understand their role in managing chronic asthma.
The asthma educator acts as a change agent, relying on effective communication skills.
credential you can get for this role
Page 4: Important Advances in Asthma Management
Last two decades have seen important advances by expert panels.
Development of evidence-based clinical guidelines focusing on:
Education
Prevention
Diagnosis
Management of asthma
Page 5: Updated Clinical Guidelines for Asthma
Based on extensive scientific research on:
Pathophysiological mechanisms
Clinical manifestations
Treatment recommendations
Regular updates from:
National Asthma Education and Prevention Program (NAEPP)
Global Initiative for Asthma (GINA)
Page 6: Overview of NAEPP
First evidence-based asthma guidelines published in 1991, updated in 2007.
Coordinated by National Heart, Lung, and Blood Institute (NHLBI) of NIH.
Guidelines structured around four care components:
Assessment and monitoring
Patient education
Control of contributing factors
Pharmacological treatments
Page 7: NAEPP Guidelines in Detail
Stepwise asthma management charts help specify optimal treatments by age:
0-4 years
5-11 years
12 years and older
Guidelines outline:
Six steps of asthma management based on control level.
Four asthma levels: intermittent, mild persistent, moderate persistent, severe persistent.
Management adjustments based on asthma control.
Recommended action plans for children and adults.
Page 8: Global Initiative for Asthma (GINA)
Established in 1993, collaborates with WHO, NIH, and NHLBI.
Works with global asthma experts, healthcare professionals, and organizations.
Page 9: Goals of GINA
Increase awareness of asthma and public health impacts.
Identify reasons for increased asthma prevalence.
Study asthma-environment associations.
Reduce asthma morbidity and mortality.
Enhance asthma management and access to treatment.
Page 10: Definition of Asthma
Asthma as a complex heterogeneous disease characterized by:
Reversible, variable recurring symptoms.
Reversible airflow obstruction.
Bronchial hyperresponsiveness (BHR).
Underlying inflammation.
During attacks, smooth muscles constrict around small airways.
Prolonged exposure may lead to muscle layer hypertrophy.
Regimen same as COPD
Page 11: Diagnosing Asthma
Hallmarks of asthma diagnosis include:
Physical examination
Medical history
Spirometry results. PFT labs
Flow rates
Pre and post bronchodilator
Diagnosis confirmed via respiratory symptoms:
Wheezing
Shortness of breath
Chest tightness
Variable cough.
Page 12: Additional Diagnostic Indications
Symptoms may worsen at night or in a seasonal pattern.
Prolonged colds lasting more than 10 days and associated allergic conditions (eczema, hay fever).
cold goes to chest
can also have eczema
Page 13: Diagnostic Criteria for Asthma (Table 8-1)
History of Variable Symptoms: Recurrent wheeze, shortness of breath, chest tightness, cough.
Spirometry Results: Criteria for diagnosing asthma include:
Variable expiratory airflow obstruction.
Significant reversibility after bronchodilator.
Presence of obstructive patterns.
Page 14: Differentiating Asthma from COPD
Diagnosis in adults involves a stepwise approach:
Identify risk of chronic airways disease.
Comparison of features to differentiate from COPD.
Asthma-COPD overlap syndrome (ACOS) may present features of both.
Page 15: Distinguishing Asthma, COPD, and ACOS (Slide 1)
Distinguishing Features:
ACOS shows age of onset >40 years; asthma typically <20 years; COPD >40 years.
ACOS is overlap of both diseases
Variability in respiratory symptoms in asthma versus consistency in COPD.
Lung function typically improves with bronchodilator in asthma.
Page 16: Asthma, COPD, and ACOS Distinctions (Slide 2)
Lung Function Variations:
ACOS: persistent airflow limitation.
Asthma: variable airflow improvement.
COPD: persistent obstruction.
History: Prior asthma diagnosis common in asthmatics, less so in COPD.
Page 17: Spirometry Measurements
Table 8-2: Comparing spirometry among asthma, COPD, and ACOS.
Post-bronchodilator results indicate airflow limitation.
Changes in FEV1 and airflow reversibility nuances across conditions.
Page 18: Clinical Signs and Symptoms (Slide 1)
No unique or universal symptom for asthma.
Classic symptoms include:
Wheezing
Chest tightness
Shortness of breath
Cough.
Page 19: Clinical Signs and Symptoms (Slide 2)
Other findings may include:
Tachypnea
Prolonged expiration
Accessory muscle use
Tachycardia.
Page 20: Triggering Factors for Symptoms
Symptoms may worsen with:
Allergen exposure (pets, pollutants)
Drug reactions (aspirin, beta blockers)
Environmental changes (cold air, chemical fumes).
Page 21: Cough Characteristics in Asthma
Cough is typically non-productive and worsens at night.
Common triggers include:
Exercise induced asthma
Cold air inhalation
Allergen exposure.
upper airway infections
Page 22: Signs and Severity of Asthma Exacerbations
Table 8-3: Different levels of severity in asthma exacerbations:
Symptoms vary from breathlessness while walking (mild) to requiring upright sitting (severe).
Alertness and speech capabilities also decrease with severity.
Breathlessness Mild, Mod, Severe, Life Threatening
Speech
Level of Conscousness
Page 23: Signs of Asthma Exacerbations (Continued)
Symptoms show increasing severity, including:
Accessory muscle use
Increased respiratory rate
Paradoxical thoracoabdominal movement.
Page 24: Etiology of Asthma
Various genetic phenotypes contribute to asthma and its allergic inflammation:
IgE response to allergens
Th2 cytokine responses.
Page 25: Environmental Factors in Asthma
Pollution and Infections:
Increased air pollution correlates with asthma outbreaks.
Viral infections (RSV, rhinovirus) significantly exacerbate conditions.
Page 26: Occupational Sensitizers and Tobacco Smoke
Occupational asthma: More than 300 substances linked to asthma development.
Tobacco smoke exposure increases asthma risk in children.
Page 27: Host Factors in Asthma
Obesity linked to increased asthma prevalence and worsened lung function.
Gender factors: More prevalent in boys pre-14; shifts to women in adulthood.
Page 28: Dietary Influences on Asthma
Certain diets linked to asthma incidence:
Formula-fed infants show higher wheezing incidence.
Western diets with low antioxidants linked to asthma.
Page 29: Additional Risk Factors (Slide 1)
Drugs: NSAIDs can exacerbate asthma.
Food additives: Specific preservatives trigger reactions.
Exercise-induced bronchoconstriction: Cold air can worsen symptoms.
Page 30: Additional Risk Factors (Slide 2)
Nocturnal symptoms common in asthmatics due to hormonal changes.
Emotional stress factors into asthma management.
Various additional syndromes worsen asthma: perimenstrual and APBA.
Page 31: Common Asthma Triggers
Common triggers include:
Pets, exercise, pollen, cold air, strong odors, dust, smoke.
Page 32: Epidemiology of Asthma
Prevalence increased from 7.7% (2014) to 7.9% (2017) per CDC.
Approx. 25 million Americans suffer from asthma; 235 million globally.
Page 33: Economic Impact of Asthma
2016 costs reported by CDC:
189,000 hospitalizations, 1.8M emergency visits.
Asthma costs exceed $56 billion per year in the U.S.
Page 34: Pathology and Pathophysiology of Asthma
Inflammatory changes characterized by infiltration of:
Eosinophils
Mast cells
Macrophages
T-lymphocytes.
Page 35: Acute Phase of Asthma
Initial response leads to bronchospasm, often resolving with bronchodilators.
Persistent inflammation follows hours after initial response.
Page 36: Normal vs Asthmatic Airways
Comparison of air trapping, smooth muscle state in normal, asthmatic, and attacked airways.
Page 37: Late Stages of Asthma
Development of late-phase reaction 6-8 hours post-acute stage.
Characterized by recruitment of several inflammatory cells (eosinophils, neutrophils).
Page 38: Asthma Inflammatory Cascade
Allergens trigger T-cell activation leading to IgE production and mast cell degranulation.
Chronic inflammation results from repeated triggers.
Page 39: During an Asthma Attack
Key processes include:
DMC: Degranulation of mast cells.
HALV: Hyperinflation of alveoli.
MA: Mucous accumulation.
Page 40: Eosinophils and Charcot-Leyden Crystals
Airway inflammation leads to eosinophil infiltration, forming Charcot-Leyden crystals in allergic asthma.
Page 41: Eosinophils in Bronchial Asthma
High magnification reveals eosinophils with distinct bright-red cytoplasmic granules.
Page 42: Overview of Charcot-Leyden Crystals
Charcot-Leyden crystals formation during eosinophil breakdown.
Page 43: Goblet Cells in Asthma
Goblet cells proliferate leading to increased mucus production, causing obstruction.
Page 44: Airway Remodeling in Chronic Asthma
Long-term smooth muscle constriction leads to irreversible airway changes.
Damaged cilia and thickened basement membrane characteristic of remodeling.
Page 45: Airway Remodeling Changes
Presentation of altered bronchial structures owing to chronic asthma and remodeling processes.
Page 46: Anatomic Changes During Asthma
Notable pathologic alterations like bronchial smooth muscle contraction typically absent between attacks.
Page 47: Summary of Changes During Asthma Episodes
Characteristic changes include:
Smooth muscle constriction
Mucous plugging
Air trapping
Bronchial inflammation.
Page 48: Ventolin V Asthma Chapter 8 Part 2 RCP 115
Page 49: Asthma Phenotypes
Phenotypes: Characteristic clusters defining asthma types based on genetics and environment.
Major Phenotypes:
Allergic, Non-allergic, Infection-induced, and Aspirin-exacerbated Respiratory Disease.
Page 50: Other Asthma Phenotypes
Additional phenotypes include:
Exercise-induced bronchospasm
Cough variant asthma with solely coughing symptoms.
Page 51: Common Risk Factors for Asthma
Table 8-7 summarizes risk factors:
Genetics, Age/Gender, Exposure to allergens and pollutants.
Page 52: Complications Associated with Poorly Controlled Asthma
Complications arise primarily from unmanaged asthma:
Daily activity interference.
Risk of respiratory failure and death.
Page 53: Risk Factors for Asthma-Related Death (Slide 1)
Important historical factors include:
Prior ICU admissions or intubation.
Multiple previous hospitalizations or emergency visits.
Page 54: Risk Factors for Asthma-Related Death (Slide 2)
Additional risk factors include:
Poor treatment adherence, economic limitations, and aeroallergen sensitization.
Page 55: Diagnostic Tests for Patients Over 5 Years of Age
FEV1 increase after bronchodilator points towards reversible airflow limitation in asthma.
PEFR improvement and ratio calculations indicative of asthma.
Page 56: Peak Flow Meter Use
Measures airflow during exacerbations, helps assess severity.
A reading below 200 L/min signals severe obstruction.
Page 57: Steps Using a Peak Flow Meter
Instructions on proper usage of a peak flow meter for accurate results.
Page 58: Pediatric Peak Flow Ranges
Predicted peak flow ranges vary by age/height, determined by green, yellow, and red zones.
Page 59: Other Diagnostic Tests for Asthma
Additional tests include:
Methacholine challenge for bronchial hyperreactivity.
Skin tests for allergen identification.
FENO levels to assess inflammation.
Page 60: Chest X-Ray Findings in Asthma Attack
Common features include:
Barrel chest appearance.
Translucent lung fields indicating hyperinflation.
Page 61: Pulse Oximetry and Blood Gases During Asthma
Monitoring SpO2 levels and ABG values aids in assessing exacerbation severity.
Different stages of ABG results provide clinical insights.
Page 62: ABG Values in Mild to Moderate Asthma
Typical values indicate acute respiratory alkalosis with hypoxemia.
Page 63: ABG Values in Severe Asthma
Results indicate chronic respiratory acidosis.
Page 64: Sputum Examination Findings
Examination reveals eosinophils, Charcot-Leyden crystals, and bronchial wall changes.
Page 65: Challenges in Diagnosing Asthma (Slide 1)
Differential diagnosis complexity at various ages:
Young children often misdiagnosed due to non-specific wheezing.
Older patients' overlapping symptoms with COPD.
Page 66: Challenges in Diagnosing Asthma (Slide 2)
Additional diagnostic challenges include exercise-induced bronchoconstriction and occupational asthma.
Page 67: General Management Guidelines for Asthma
GINA provides guidelines on managing and diagnosing asthma effectively, accessible on their website.
Page 68: Primary Goals of Asthma Management
Aim to control asthma manifestations, maintain normal activity, and prevent exacerbations and mortality.
Page 69: GINA Management Components
Five components for managing asthma:
Patient/Doctor partnership.
Identify/reduce risk exposure.
Assess and monitor asthma.
Manage exacerbations.
Special considerations for unique patients.
Page 70: Patient/Doctor Partnership
Essential for effective asthma management; encourages patient autonomy through education and planning.
Page 71: Identifying and Reducing Risk Factors
Identify triggers and advise on avoidance strategies.
Page 72: Assess, Treat, and Monitor Asthma
Systematic approach to assessing control, adherence, and overall treatment effectiveness.
Page 73: Control Versus Severity
Severity fluctuates; past management based on severity misguides treatment predictions.
Page 74: Asthma Severity Classification (Table 8-10)
Symptoms and event frequency guide severity classification from intermittent to severe.
Page 75: Step Therapy Approach
Treatment adjustments based on control levels; progressive medication increases if symptoms aren't controlled.
Page 76: Step Therapy for Persistent Asthma in Older Children & Adults
Specific steps for varied treatments depending on symptom control; includes combinations and specialist consultation.
Page 77: Monitoring and Maintaining Control
Regular monitoring through a personalized Asthma Action Plan improves management consistency.
Page 78: Sample Asthma Action Plan
Outlines specific actions based on symptom control, guiding proper medication use at various levels.
Page 79: Managing Asthma Exacerbations
Definition and measurement of severity in asthma exacerbations based on symptoms and airflow limitations.
Page 80: Classifying Severity of Exacerbations (Table 13-4)
Objective criteria classify exacerbations from mild to imminent respiratory arrest based on symptoms and monitoring.
Page 81: Primary Therapies for Asthma Exacerbations
Key treatments involve bronchodilators, glucocorticoids, and supplemental oxygen.
Page 82: Special Considerations in Asthma Management (Slide 1)
Unique scenarios like pregnancy and obesity lead to specific management adaptations.
Page 83: Special Considerations in Asthma Management (Slide 2)
Surgery needs close pre-op assessment and planning.
Page 84: Special Considerations in Asthma Management (Slide 3)
Addressing occupational asthma through total exposure avoidance is crucial.
Page 85: Special Considerations in Asthma Management (Slide 4)
Recognizing GERD in asthmatics is essential for comprehensive care.
Page 86: Anaphylaxis and Asthma Relationship
Symptoms may overlap; both require aggressive management and monitoring.
Page 87: Treatment Protocols for Aerosolized Medications
Effective treatments include inhalation techniques for rapid relief and management.
Page 88: Oxygen Therapy Protocols
Use of oxygen therapy to combat hypoxemia associated with asthma exacerbations.
Page 89: Bronchopulmonary Hygiene and Mechanical Ventilation Protocols
Effective techniques for managing mucus and severe asthmatic conditions via mechanical support.
Page 90: Asthma Management in Acute Care
Structured assessment and treatment protocols during acute asthma exacerbations for patient safety.
Page 91: Bronchial Thermoplasty as a Treatment
Bronchial Thermoplasty reduces airway smooth muscle to control severe asthma symptoms effectively.
Page 92: Summary of Bronchial Thermoplasty
Treatment details and expected outcomes after Bronchial Thermoplasty.