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:

  1. Patient/Doctor partnership.

  2. Identify/reduce risk exposure.

  3. Assess and monitor asthma.

  4. Manage exacerbations.

  5. 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.