Asthma bronchiale •MUDr. Vladimír Herout •Department of pulmonology, •University hospital Brno •Masaryk University, faculty of medicine Logo%20FN untitled • •Definition? ANd9GcQlLSeT-DPAKp0wmHqZcMyofl_qdcN_ieNs8L8h6n4JahXfKHwv ANd9GcSQhJ9SpS90BJ5ET8Bxej65Y4bVfiEu362nRSj-Aly6gT-00kk1_g 1268688278lukas-bauer • Definition? beckham Definition •Asthma is a chronic inflammatory disorder of the airways conected with their structural changes. Chronically inflamed airways are hyperresponsive, they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors. • COPD – definition (difference x astma) •COPD (chronic obstructive pulmonary disease) is a lung disease that cause obstruction of the airways. •Even with treatment, COPD is not completely reversible and usually worsens over time. Symptoms •Recurrent episodes of wheeze, dyspnoea, chest tightness, and cough, particularly at night or in the early morning. • Epidemiology •one of the most common chronic diseases •prevalence worldwide 1-18% •most common especially in developed countries –Great Britain 10% –Czech Republic 8% Epidemiology •asthma predominantly occurs in boys in childhood, with a male-to-female ratio of 2:1 until puberty •asthma prevalence is greater in females after puberty •the majority of adult-onset cases diagnosed in persons older than 40 years occur in females economic burden •in the United States, for example, annual asthma care costs (direct and indirect) exceed US$6 billion • Etiology a pathogenesis •genetic factors + exogenous influence (allergens, infection, tobacco smoke, …) • • •Main genetic predisposition factor for developing asthma is atopy (hyperproduction of IgE) Etiology a pathogenesis •Stimuli that can cause asthma: – –early childhood infections – –chemical exposure through air pollution – –insufficient immune system development • • Asthma_Bronchial-3 Clinical symptoms •Recurring episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. • •Phenotype druhy-postav Definition • •Phenotypes result from the expression of an organism's genes as well as the influence of environmental factors and the interactions between the two. Phenotype of asthma (curability) •good •Eosinophilic asthma with allergy • •Eosinophilic asthma without allergy • •Non-eosinophilic asthma • •bad • •What examination can we routinely use to divide astma according to phenotype? Phenotype of asthma •Exhaled nitric oxide (FeNO) –fractional exhaled nitric oxide (FeNO) –noninvasive marker of eosinophilic airway inflammation –FeNO level is normal in well-controlled asthma • Phenotype of asthma •Induced sputum –produced for diagnostic tests by aerosol administration of a hypertonic saline solution – •eosinofilia •neutrofilia •paucigranulocytic phenotype of asthma • Phenotype of asthma •Bronchoscopy –BAL –Bronchial biopsy » thickened basement membrane » cell infiltration in submucosa » smoothmuscle hypertrophy prudusky Diagnosis •Medical history •Spirometry (measurements of lung function) –evidence of the bronchial obstruction, its reversibility and variability –normal spirometry does not exclude asthma bronchiale •Reversibility of bronchial obstruction – –Positive bronchodilatation test - 12% or more improvement in FVC or FEV 1 after administration of bronchodilatator – ( salbutamol…) – • ANd9GcTl0joOfLIcupcXa5vrvBtFJTw1exYsE9v3f74u7NHgtjxJJxJj9Q •Measurements of bronchial hyperreactivity (bronchoconstriction test) –for patients with symptoms consistent with asthma, but normal lung function –measurements of airway responsiveness to metacholine and histamine –(an indirect challenge test such as inhaled mannitol, or exercise challenge) Treatment - history •1969: beta-2 agonists •1974: inhaled corticosteroids • •There is now good evidence that the clinical manifestations of asthma—symptoms, sleep disturbances, limitations of daily activity, impairment of lung function, and use of rescue medications—can be controlled with appropriate treatment. Non-farmacological treatment •Identify and reduce exposure to risk factors – strategies for avoiding common allergens and pollutants Farmacological treatment •Medications in two broad categories: • •Quick relief of symptoms – bronchodilatators – •Long term control of persistent asthma –antiinflamantory and preventive •Inhaled medications are preferred because it deliver drugs directly to the airways where they are needed, resulting in potent therapeutic effects with fewer systemic side effects. Quick relief therapy •RABA (rapid-acting beta-2 agonists) –SABA (short-acting beta-2 agonists) •fenoterol, salbutamol, terbutalin –formoterol (LABA – long acting beta-2 agonists) •SAMA(short-acting muscarinic antagonist ) •ipratropiumbromid •i.v. theofyllin, systemic corticosteroids • Long term control therapy •Inhaled corticosteroids •LABA (long acting beta-2 agonists) •Antileukotriens – montelukast, zafirlukast •Retarded theofyllins •Systemic coticosteroids •Anti-IgE (omalizumab) • •First choice therapy of persistent asthma is inhaled corticosteroids. • Asthma Classification of asthma by level of control • •The goal of asthma care is to achieve and maintain control of the clinical manifestations of the disease for prolonged periods. • • • • • • • Asthma Classification of asthma by level of control Characteristics Daytime symptoms Limitation of activities Nocturnal symptoms Need for reliever/rescue inhaler Lung function (FEV1, PEF) exacerbations Controlled (All of the following) 2 or less/week None None 2 or less/week Normal None Partly controlled (Any measure presented) More than 2/week Any Any More than 2/week under 80% predicted 1 and more/year Uncontrolled 3 or more features of partly controlled asthma DCA = Difficult-to-control asthma •Difficult-to-control asthma (DCA) can be described as an unability to reach satisfactory asthma control after 6 months of appropriate antiasthmatic therapy (including high doses of inhaled corticosteroids) and patient compliance to this therapy is good. • National Center for Severe Asthma in the Czech Republic •Estabilish in 2006 •8 centers in Czech rep. •http://www.tezke-astma.cz • Severe asthma 1.Controlled – only with intensive treatment 2.Uncontrolled –bad compliance –persistent comorbidities – gastro-oesophageal refluxive disease, rhinosinitis –DCA Managing of severe asthma exacerbation •oxygen •nebulised beta-2-mimetics •nebulised ipratropium bromide •i.v. corticosteroids •magnesium i.v. •NIV •intubation, ventilation • Differential diagnosis •COPD •Foreign body •Vocal cord dysfunction •Heart failure - „Cardiac asthma“ – •Onemocnění průdušnice –stenóza –cizí těleso •Tracheobronchomalacie •Onemocnění průdušek –akutní bronchitida –Bronchiolitida –… – • Prognosis •good •5 % difficult-to-control asthma (DCA) • • Questions? • http://www.asthmacontroltest.com •