Bronchial Asthma

NK  Gami

Lung and Pleura

Bronchial Asthma1

Asthma is a common disease and defined as chronic inflammatory disorder of the airways.

ESSENTIALS OF DIAGNOSIS

Clinical	Investigation
Episodic or chronic symptoms of airways obstruction: Breathlessness Cough Wheezing Chest tightness Prolonged expiration, diffuse wheezing and rhonchi on physical examination	Pulmonary function tests: (Table 1.1) Limitation of airflow Positive bronchial provocation challenge Complete or partial reversibility of airflow obstruction, either spontaneously or following bronchodilatation therapy

Table 1.1 Pulmonary function test in bronchial asthma

	Spirometry:
I.	a. FEV 1 (Forced expiratory volume in the first second) b. FVC (Forced vital capacity) Fall in the ratio of FEV1 to FVC points to airway obstruction due to asthma, COPD, bronchiectasis and upper airway obstruction
II.	Spirometry repeated after use of bronchodilators. In asthma relief is obtained

MANAGEMENT

Antiasthmatic Drugs

Classification:

I. Long-term medications:	1. Corticosteroids:
	Inhaled corticosteroid:
	Beclomethasone dipropionate Fluticasone		Budesonide Triamcinolone, acetonide
	Systemic corticosteroids:
	Prednisolone tablet		Methylprednisolone tablet
	2. Cromolyn inhaler 3. Long acting B2 agonists:
	Salmeterol inhaler		Salmeterol sustained release tablet
	4. Theophylline tablet
	5. Leukotriene modifiers tablet (Montair-Cipla 10 mg tablet)
2
II. Quick relief medications:	1. Short acting inhaled B2 agonists:
	Terbutaline	Salbutamol	Albuterol
	2. Anticholinergics:
	Ipratropium inhaler
	3. Systemic corticosteroids:
	Prednisolone tablet	Methylprednisolone tablet

Individual Drugs

See “Properties and Dosages of Antiasthmatic Drugs” (Table 1.5)

TREATMENT OF CHRONIC BRONCHIAL ASTHMA

Table 1.2 Treatment of chronic bronchial asthma

	Long-term management	Immediate relief medications	General advice
Mild intermittent bronchial asthma	Intermittent use of short acting bronchodilators: No daily medication needed	Inhaled short acting B2 agonists during exacerbation of symptoms	Teach about basics of asthma (Table 1.3)
	Inhaled short acting B2 agonist: 1–2 puffs intermittently		Teach about drugs: Inhalant Oral drugs Teach about preventive measures (Table 1.4) Self-monitoring
Mild persistent asthma	Regular inhaled bronchodilators and inhaled corticosteroids on daily basis:
	Inhaled short acting B2 agonist once daily Beclomethasone or budesonide 100–400 microgram b.d. or fluticasone 50–200 microgram b.d.	Inhaled short acting B2 agonist daily as needed for relief of symptoms	–Do–
	or
	Cromoglycate inhalation
	or
	Corticosteroid inhalation daily if symptoms not controlled
Moderate asthma	Mid or low dose inhaled corticosteroid + long acting inhaled B2 agonist and sustained release theophylline:	Inhaled short acting B2 agonist as needed for symptoms	–Do–
	Inhaled mid or low dose corticosteroid
	or
	Long acting bronchodilator
3
	Long acting inhaled B2 agonist or B2 agonist (long acting) tab: Salmetrol
Severe asthma:	High dose inhaled corticosteroid + regular bronchodilator:	Inhaled short acting bronchodilator on daily basis + inhaled corticosteriods	–Do–
	High dose inhaled corticosteroid on daily basis	Inhaled short acting B2 agonist as needed for symptoms
	Plus long acting inhaled B2 agonist plus sustained release theophylline
	Corticosteroid tablet or syrup (2 mg/kg)	Nebulised B2 agonist
	Leukotriene antagonist recently introduced	Inhaled corticosteroid
	⇓
	Review treatment every 3–6 months. If control is achieved stepwise reduction in treatment may be possible.

TREATMENT OF ACUTE ASTHMA

Table 1.3 Education for asthma patient

Teach about basics of asthma

Teach about recognising symptoms-mild, moderate and severe

Teach about adjusting dose of drugs according to symptoms

Teach about prevention of asthma

Table 1.4 Prevention

Stop smoking

Stop allergens, for example, dust

Spirometry repeated every 1 to 2 year

Patient with persistent asthma should receive annual influenzal vaccine

Table 1.5 Properties and dosages of antiasthmatic drugs

Drugs action	Dosages and route of administration	Indications	Side-effects contraindication	Advantages	Disadvantages
Epinephrine: Both alpha and beta effects	0.3 cc 1/1000 solution SC	Acute asthma	Tremor, palpitation, arrhythmias. Avoidded in elderly and IHD		Tolerance develops after repeated use
Terbutaline: Selective B2 agonist bronchodilatation without cardiac side-effects	2.5 to 5 mg 2 to 3 times a day. Capsule 5 to 7.5 mg b.i.d. Inhalation 250–500 mcg 3–4 times a day SC, IM, IV: 0.25 mg up to 4 times/day Tab 2.5, 5, 7.5 mg Inj. 0.5 mg/ml	SC, IM, slow IV in acute asthma Nebulising solution in severe asthma Prophylaxis against exercise induced asthma: Inhalation.	CI: Cardiac cases with arrhythmias, pregnancy, hypertension, hyperthyroidism	Rapid onset, longer duration More effective with steroid	Tolerance develops. No anti-inflammatory effect (always combine with steroid)
Salbutamol: Selective B2 agonist Salmeterol: Long acting B2 agonist	2 to 4 mg 3 to 4 times/day Extended release tab 4 to 8 mg twice/day Inhalation: 100 to 200 mcg 3 to 4 times/day 50 mcg inhalation up to 100 mcg b.d.	For regular use in chronic asthma. Prophylactic use	CI: Thyrotoxicosis, hypertension, pregnancy CI: Thyrotoxicosis, hypertension, pregnancy, IHD, arrhythmia. Side-effects: Palpitation, tremor	May be combined with low dose inhaled steroid with less side effect
Sodium chromoglycate: Reduces release of histamine by inhibiting mast cell degranulation, redu-ces bronchial sensitivity. No bronchodilatation or antiinflammatory effect	2 puffs q.i.d. 2 puffs 15 mts before exercise or cold exposure Aerosol inhaler Aerosol inhaler	Prophylactic use. Prevents exercise induced or cold induced asthma. Not used in acute asthma		Low side effect. In responsive patients steroid may be reduced or stopped	Less effective than inhaled steroids. Short acting and need to be taken 4/day. More expensive
Steroids: Anti-inflammatory action	Methylprednisolone 125 mg IV 6 hourly Efcorlin 100 mg IV Inhaled steroid Oral steroid as maintenance dose once in morning or alternate. May be added to IV steroid in acute asthma	Status asthmaticus Prevention	Adrenal and growth suppression, osteo-porosis, cataract, bruises, oral candidiasis
Theophylline	Orally 80 to 240 mg t.i.d.		Arrhythmia, tachycardia, tremor	Only orally twice daily. Inexpensive	Drug interaction less. Well-tolerated
6
Bronchodilator and anti-inflammatory action	Sustained release tablet 400 mg in 2 divided dosages—increased to 800 mg/day IM or IV Deriphyllin 2 ml amp b.d. or t.d.s.
Ipratopium: Anticholinergic bronchodilator	Inhalation		Glaucoma, prostate enlargement. Side effects like atropic
Leukotriene antagonists: Leukotriene causes bronchoconstriction, leukotriene antagonists cause bronchodilatation and also anti-inflammatory	Zafirlukast: Twice daily Montelukast: Once daily			Active orally. Works quicker (within first 24 hr) than steroids No tolerance Additive effect with steroid. Effective in allergic rhinitis also. Well-tolerated	More expensive than inhaled steroid
Cetrizine, loratidine: Antihistaminics	Once daily			Effective in allergic rhinitis

Chapter Notes

Bronchial Asthma1