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Asthma

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WHAT IS ASTHMA?

Asthma is a chronic inflammatory disorder of the airways resulting in, variable airflow bronchial obstruction which is potentially reversible with appropriate therapy or spontaneously. It is typically characterized by episodic attacks of breathlessness, cough, and wheezing (“asthma triad”).

EPIDEMIOLOGY
  • Approximately 4.3% prevalence worldwide
  • Children > Adults
  • Blacks > caucacians
  • Sex distribution
    • Children: Boys > Girls
    • Adults: Females > Males
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What changes
take place in the lungs when pollen enters the airways?

  • Inflammation
  • Subepithelial collagen deposition
  • Thickening of submucosa due to oedema and cellular infiltration
  • Airway Obstruction
  • Constriction of smooth muscles
  • Increase mucus production in the airway lumen

What Causes Asthma?

It isn't clear why some people get asthma and others don't, but it's probably due to a combination of environmental and genetic factors (25-80% degree of heritability).

Clinical features of Asthma

  • The characteristic symptoms of asthma are
    • wheezing,
    • dyspnea and
    • coughing, which are variable, both spontaneously and with therapy.
  • Symptoms may be worse at night and patients typically awake in the early morning hours.
  • Difficulty in filling their lungs with air
  • There is increased mucus production in some patients, with typically tenacious mucus that is difficult to expectorate.
  • There may be increased ventilation and use of accessory muscles of ventilation.
  • Prodromal symptoms may precede in attack, with itching under the chin, discomfort between scapula, or inexplicable fear (impending doo
  • Typical physical signs are –
    • inspiratory, and to a greater extend expiratory,
    • rhonchi throughout the chest and
    • there may be hyperinflation (happen when some air gets trapped in the lungs when breathing out).

Exposures & risk factors related to the development of asthma

  1. Allergen exposure in those with a predisposition to atopy
  2. Occupational exposure
  3. Air pollution
  4. Infections (viral & mycoplasma)
  5. Tobacco
  6. Obesity
  7. Diet
  8. Fungi in allergic airway mycoses
  9. Acute irritants and reactive airway dysfunction syndrome (RADS)
  10. High-intensity exercise in elite athletes

Triggers of Airway Narrowing

  1. Allergens
  2. Irritants (household sprays, paint fumes)
  3. Upper respiratory tract viral infections
  4. Exercise and Hyperventilation
  5. Cold, dry air
  6. Air pollution (sulfur dioxide &irritant gases, ozone, NO2)
  7. Drugs (β blockers, aspirin, ACE inhibitors)
  8. Occupational exposures
  9. Hormonal changes (increase in perimenstrual/perimenopausal symptoms)
  10. Pregnancy

COMORBIDITIES THAT
CAN MAKE ASTHMA DIFFICULT TO CONTROL

  1. Obesity
  2. Gastroesophageal reflux disease (GERD)
  3. Chronic rhinosinusitis
  4. Inducible laryngeal dysfunction (Vocal cord dysfunction)
  5. COPD
  6. Anxiety/Depression
  7. Obstructive sleep apnea

DIAGNOSIS AND EVALUATION

APPROACH

  • Presumptive diagnosis: History of wheezing, Shortness of breath, chest tightness or cough following trigger exposure.
  • Therapeutic trial of low dose ICS (inhale corticosteroids)
  • Confirmation-
  • Pulmonary function testing
  • Demonstration of airway hyperresponsiveness
  • Primary Assessment Tools: For making diagnosis of Asthma
  • Adjunctive Assessment Tools: Identify precipitants & underlying mechanisms – exact therapy

Primary assessment tool

  • History
    • Episodes of wheezing, shortness of breath, chest tightness, mucus production or cough upon exposure to triggers
    • Worsening in morning
    • Precipitation with rapid change in temperature
    • Exercise/cold air induced symptoms
    • 2/3rd of patients are atopic
    • H/O recent drug use? – NSAIDS, β blockers, ACE inhibitors
  • Physical Examination
    • Pale nasal mucosa: associated with allergic rhinitis
    • Acute attack: tachypnea, tachycardia, use of accessory muscles
    • On Ascultation, Wheezing à Silent chest
  • Pulmonary Function Tests
    • ↓ PEFR, FEV1 & FEV1/FVC
    • Flow volume curve: Scalloping
    • Reversibility – After giving β2 agonist àafter 15 minutes, >12% or 200ml ↑ in FEV1
    • Peak flow Diurnal variation of >20%
  • Assessment of Airway responsiveness
    • ↑ reactivity to provocative stimuli (done in loborartory)
    • Methacholine: >20% drop in FEV1 with a dose <400ug
    • Mannitol
    • Hypertonic saline
    • Exercise/cold air > 10% drop in FEV1

Adjunctive Assessment tool

  • Eosinophil counts
    • >300 cells/ul
    • Response to medications targeting Type 2 inflammation
    • Extremely elevated levels —- Eosinophilic granulomatosis with polyangiitis /Primary eosinophilic disorders/ Churg-Strauss Syndrome
  • IgE, skin tests & Radioallergosorbent Tests
    • Total serum IgE >1000 IU/ml: s/o ABPA (Allergic Bronchopulmonary Aspergillosis)
    • Skin Tests or RAST : Confirm atopy
  • Exhaled Nitric Oxide:
    • FeNO: Approximate indicator of eosinophilic inflammation in the airways
    • Easily suppressed by Inhalational corticosteroids
    • Untreated patients (>35-40ppb)- eosinophilic inflammation
    • Treated patients (>20-25 ppb)- poor adherence to therapy or persistent type 2 inflammation
  • Chest radiography – Radiograph of the chest may show hyperinflation in a patient with asthma. It may also reveal complications of severe asthma such as rib fracture, pneumothorax, and pneumomediastinum
  • Sputum examination
    • Eosinophils (Type 2 inflammation) vs Neutrophils (Non Type 2 inflammation)

TREATMENT

Goals of Therapy

  1. Reduction in symptom frequency to <2 times/week
  2. Reduction of night time awakening to <2 times/month
  3. Reduction of reliever use to <2 times a week (except before exercise)
  4. No more than 1 exacerbation/year
  5. Optimization of lung function
  6. Maintenance of normal daily activities.
  7. Satisfaction with asthma care with minimal or no side effects of treatment.
  • Reducing triggers –By Mitigation, Allergen immunotherapy, Vaccination
  • Medications
  • Reliever medications/Bronchodilaters
    • β2 agonists
    • Short acting (Salbutamol)
    • Long Acting (Formeterol, salmeterol)
    • Ultra long acting (Indacaterol, Vilanterol)
    • Anticholinergics (Ipratropium, Tiotropium)
    • Theophylline
  • Controller Medications/ Anti-inflammatory
    • Corticosteroids
    • ICS, ICS/LABA
    • Oral, IV, IM
  1. Leukotrienes Modifiers
    • CysLT1 Antagonists (Montelukast, Zafirlukast)
    • 5-LOX inhibitors (Zileuton)
  2. Mast Cell Stabilizer (Cromolyn Sodium)
  3. Anti IgE (Omalizumab)
  4. Anti IL-5 (Mepolizumab, Reslizumab)
  5. Anti IL-4/13 (Dupilumab)

Treatment -Asthma attacks

Mild to moderate- MDI β2 agonists administered every 1hr or ↑ the dose of ICS by 4-5 times

Nebulised β2 agonists upto every 20 min

Inravenous corticosteroids

Other measures

  1. Supplemental oxygen
  2. LTRA & magnesium
  3. Nebulised anticholinergics
  1. Non invasive pressure ventilation
  2. IV Antibiotics
  3. Mechanical ventilation : Permissive Hypercapnia

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drrashmi@ccubehomeopathy.com

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