Asthma

Background
Definition
Asthma is a heterogenous chronic inflammatory disease characterised by reversible airway
obstruction, airway hypersensitivity and airway inflammation. Patients usually presents with
symptoms like cough. Wheezing, Chest tightness, Breathlessness.

Epidemiology
Asthma is the commonest chronic respiratory disease affecting children. Patients usually present
when they are children (including pre-schoolers and schoolers) and young adults, but it affects people
of all ages. The incidence of asthma is increased in developed countries. In addition, asthma is also
present with certain occupations where they expose to potential sensitizers.

Pathophysiology
Exact pathophysiology is not fully understood. And it is thought that genetic factors(collection of
genes) ,environmental factors and atopy(An umbrella term for increased tendency for having
asthma, allergic rhinitis, eczema) a play a role in the development of the disease. They aetiological
factors leads to chronic bronchial inflammation where Th2 play a predominant role and secretes
various cytokines leading to an hypersensitive airway to various triggers resulting in reversible
airway obstruction. Repeated bouts of asthma attacks will lead to airway remodelling where there is
hypertrophy of bronchial smooth muscles, mucous secreting glands and vascularity.

Based on the pathophysiology, asthma can be further classified into,

1. Atopic asthma

Type 1 hypersensitivity reaction to inhales allergen and IgE mediated.

Most of the time there is a positive family history and a family history of atopy.
Positive skin prick test

2. Non atopic asthma

Usually there is no evidence of positive family history of asthma and atopy

Respiratory infections (predominantly viral) exposure to pollutants reduces the threshold of
the vagal afferents resulting in asthma

3. Occupational asthma

Many substances have been have identified as potential sensitizers and chronic exposure to
these substances results in asthma. Atopic individual develops asthma more rapidly when
they are exposed these sensitizers than non-atopic individuals.

4. Drug induced asthma

Common offenders are Aspirin, indomethacin and beta blockers.

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Presentation
Symptoms Cough, Wheezing, Breathless, Chest tightness
The affected individual is dyspnoeic and tachypnoeic.
On general examination check for inhaler use, check nasal mucosa
for sings of allergic rhinitis, oral thrush, check for signs of eczema
especially on the extensor surfaces and sings of vasculitis.
Signs Inspection
In addition, comment about the growth of the child
On respiratory examination check for use of accessory respiratory
muscles, intercostal recessions.

Palpation Reduced chest movements

Percussion Normal
Expiratory polyphonic wheezes (Indicates obstruction of differently
Auscultation
sized airways.

Differential diagnoses
In paediatric patient, when the presenting complain is wheezing

Viral episodic Wheezing episode is preceded by a viral infection of the respiratory tract.
wheezing Risk factors – Prematurity, Maternal smoking
Multiple trigger Most of these patients will progress into asthma. Wheeze is triggered by cold
wheeze air, exercise, pollens and etc.
Bronchiolitis Mainly infants
Chronic aspiration
Cystic fibrosis
Recurrent
anaphylaxis
Bronchopulmonary
dysplasia

In paediatric patients where chief complain is chronic cough (Lasting more than 4 weeks)

• Upper airway cough syndrome

• Recurrent post viral cough
• Protracted bacterial bronchitis
• TB
• Bronchiectasis
• Foreign bodies
• Aspirations (Chronic)
• Bronchopulmonary dysplasia

In the history ask for the nature of the cough, any diurnal variation, sputum production,
exacerbating and relieving factors how the child in between the episodes and response to
bronchodilator therapy, atopy and family history may drive the diagnosis toward asthma.

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 In adult patients they usually present with an acute exacerbation asthma with breathlessness,
chest tightness, cough and wheezing.

DDs

Asthma – Previous history of similar episodes, Diurnal variation, Atopy, Family history, Use of
bronchodilators and symptom preventers
Severe pneumonia – Fever, Breathlessness, Pleuritic rest pain, Rusty sputum and etc.
Pleural effusion – Tuberculosis, Pleuritic chest pain
Pulmonary embolism -Risk factors (Recent surgery. OCP use, prolonged immobilization
Infective exacerbation of COPD – Fever ,Sputum , Risk factors
Acute heart failure – Valvular diseases, Myocardial infarction, Orthopnoea, PND, Risk factors,
Bi basal crackles
Acute kidney injury -Pre renal, Renal, Post renal factors
Anaemia – Fatigue, Malaise, Blood loss, Nutrition.

Aetiology (causes)
M Metabolic / endocrine
I Infective / iatrogenic Infective exacerbations (Mainly viral)
D Degenerative
N Neoplastic
I Inflammatory/ immunological Atopic individuals
G Genetic/ congenital Genetic factors play a roles in atopic asthma
H Haematological/ vascular Some vasculitic conditions (Churg Strauss Syndrome)

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 T Traumatic / toxins Drugs like aspirin , And other NSAIDS, Beta blockers

Risk factors
Intrinsic

• Family history
• Atopy

Extrinsic

• Exposure to precipitating factors

• Chronic exposure to sensitizers
• Active and passive smoking
• Viral infections
• Drugs (Mentioned above)

Investigations
Diagnosis is mainly clinical. There is no specific diagnostic test.

Peak expiratoryflow Reduced PEFR in relation to the nomogram. Used mainly to asses
rate progression the disease and response to the therapy. Measured after
waking up and before after the bronchodilator therapy. Mainly used
because of its portability. Diurnal variation of than 20% considered as
diagnostic
Spirometry Decreased FEV1/FEV. More sensitive than PEFR.
Skin prick test In ideal setting all the patients with asthma should undergo skin prick
test to identify the allergens.
Exhaled nitric oxide Measures airway inflammation
Bronchial provocation Transient airway obstruction is induced.
test
Allergen provocation
test
Blood and sputum tests May demonstrate eosinophilia.

Management
Goals
• Abolish the symptoms
• Restore the lung function to the normal level
• Minimize the risk of future exacerbations
• In children ensure the normal growth
• Minimize school and occupational absence

Non pharmacological
• Patient and family education about asthma
• Patient and family education about the drug treatment
• Avoidance of precipitating factors

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 • Cessation of smoking
• Avoid using causative drugs
• Exercise (In Illustrated paediatrics it is mentioned that exercise does not play a role in asthma)
• Psychological interventions
• Losing weight in obese

Pharmacological
• Cornerstone of management is inhaled corticosteroids. (Ex- Beclomethasone, Budesonide,
Fluticasone, Mometasone)
• Symptom relievers are used in acute attacks (SABA-Salbutamol, Terbutaline, LABA –
Salmeterol, Formoterol, SAMA – Ipratropium)
• As symptom preventers Leukotriene receptor antagonist like Montelukast can be used and
mast cells stabilizers like sodium cromoglycate can used in certain population.
• In subset of population where asthma is resistant to steroids Steroid sparing drugs like
methotrexate and ciclosporins are used.
• Anti-IgE antibodies – Omalizumab (Given subcutaneously)

Management of asthma is guided by the GINA stepwise therapy of asthma.

Adults mx principles

• Using SABA inhaler alone is not recommended. (Only in mild intermittent asthma)
• For control of symptoms – ICS + SABA (Both as and when needed)
• ICS + Formoterol in single inhaler (Formoterol has rapid onset of action) And increased
compliance.
• If not controlled step up – Maintain and Reliever therapy- ICS + Formoterol (Reliever +
Maintenance)
• Step down if the symptoms are controlled for 2-3 months

Paediatric management principles

• Principles are same as for the adults.

• Principles varies with age categories

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Important

• Review the inhaler technique

• Ensure compliance
• Advise about the adverse effects
• Follow up the patient
• Avoidance of the risk factors

Surgical
• Bronchial thermoplasty – It is a bronchoscopic procedure where it uses radiofrequency waves
to reduce the bronchial smooth muscle mass.

Complications
Early Severe exacerbation
Late Growth retardation in children
Learning disabilities
Adverse effects of medicines – Weight gain
Spontaneous pneumothorax
Depression
Absence from school and occupation

Management of Acute asthma

In adults

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In paediatrics

References

• Kumar and Clark’s Clinical medicine

• Davidson’s Principles and Practice of Medicine
• Illustrated textbook of paediatrics
• Lecture notes of pulmonology module

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