Você está na página 1de 24

Definition: (ATS, 1962)

Respiratory disease Tracheo-bronchial hyperreactive Diffuse narrowing Reversible (disappear with or without treatment)

Definition (GINA, 2002)


Asthma is a chronic inflammatory disorder of the airway in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithel cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathless, chest tighness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or without treatment. The inflammation also causes an associated increase in the exizting bronchial hyperresponsiveness to a variety of stimuli.

Definition (National Guidelines)


Cough and/or wheeze that:
Episodic Variable Reversible

Atopic history

Prevalence of asthma
Primary school children (6-13 year old) Secondary school children (12-18 year old) 4 17 % 5.7 7.4 %

Hospitalized children
2.7% with asthma, usually with other diseases such a pneumonia or ARI

Triggers of asthma
Respiratory infection (viral, mycoplasma) Exercise Allergens : - Inhaled - Ingested (rare) Irritants (cigarette smoke, air pollution) Weather changes Medications (ASA) Chemical (tartrazine, sulfites, menosodium glutemate) Emotional stress Gastroesophageal reflux

Genetically predisposed individuals


Inducers (I) Indoor allergens Alternaria, etc

? Avoidance
Immune response Th2, IgE, IgG4, IgG1

Enhancers (E) Rhinovirus Ozone b2-agonist


Triggers Exercise/cold air Histamine/methacholine

Avoidance Anti- inflammatories Immunotherapy ?

Inflammation Th2, Mast cells, eosinophils

BHR
b2-agonist

Wheezing
Platts-Mills et al. Ciba foundation 1997

Inflammatory cell recruitment

Persistence of Inflammatory cells decreased apoptosis

Activation of fibroblasts & macrophages Tissue Repair & remodelling

Vascular Permeability & oedema Inflammatory Mediator release Mucus secretion & bronchoconstriction

Inflammatory Cell activation

Release of Cytokines And growth factors

Smooth muscle & mucous gland proliferation Epiteliel cell Activation & proliferation

Increased Bronchial hyperreactivity

Mechanisms of acute and chronic inflammation in asthma and Remodeling processes

Chronic Acute inflammation inflammation

Airway remodelling

Symptoms (Bronchoconstriction)

Exacerbation Persistent airflow obstruction Non-specific hyperreactivity

Link between pathologic mechanism and clinical consequences in asthma

Smooth muscle mass increase

Mucous glands increase

Inflammatory cells persistence

Fibrogenic growth Elastolysis factor release

Severe bronchospasm during exacerbation

On going inflammation

Reduced elasticity of airway wall

Important mucous secretion during exacerbation

Colagen deposition on RBM and RCM

Clinical consequences of airway remodeling in asthma

Criteria of severity of childhood asthma


Infrequent episodic symptoms
Exacerbation 3-4 x/year, there is no sign and symptom in between Quality of life good

Frequent episodic symptoms


Exacerbation 1 x/month, there is no sign and symptom in between Quality of life good, sometimes affected

Persistent symptoms
Exacerbation > 1 x/month, there is sign and symptom in between Quality of life limited

Risk factor for persistence of childhood asthma


Sex Age of onset Conflicting evidence Yes; early onset

Severity of asthma
Eczema Family history of atopy Smoking (active/passive) Level of lung function Treatment

Yes; more severe


Yes Yes Yes Yes; impaired lung function at age 7 predicts asthmatic symptoms Not known

Do not over treat to avoid side effects


Paton J. Manual of asthma management, 2001

DIAGNOSIS
Cough and/or Wheeze Clinical history Physical examination Mantoux test
Indeterminate features or suggestive of alternative diagnosis Neonatal onset
Failure to thrive Chronic infection Vomiting/choking Focal lung or CVS signs

Suggestive of asthma:
Episodic Nocturnal Seasonal Exertional Atopy

If possible frequent peak flow measurements : Reversibility (20%)


Variability (20%)

Consider Chest and sinus x rays Lung function Bronchial challenge and/or Bronchodilator response

Bronchodilator response
Response

No response

.. Consider : Sweat test Immune function Ciliary & Reflux studies

WD/ Asthma Assess severity and aetiology Chest x ray if more than mild episodic disease
Trial of antiasthma treatment

- ve

+ ve

Alternative diagnosis and treatment

Consider asthma as an associated problem

Not asthma

Review diagnosis and compliance if poor response to treatment

Treatment
Treatment of attack :
b2 agonist Ephinephrin Theophyllin/aminophyllin Steroid : inhaled, nebulized, oral : subcutan : oral, I.V. : oral, I.M.

Prevention of attack :
Avoidance
Medicine

: triggers (including enhancers, inducers) especially improve indoor environment. : steroid, DSCG, antileukotrien, ketotifen, cetirizine.

Longterm management

Low dose steroid

Medium dose steroid

Low dose steroid + LABA

Low dose steroid + ALTR

Low dose steroid +TSR

High dose steroid

Medium dose steroid + LABA

Medium dose steroid + ALTR

Medium dose steroid + TSR

ORAL STEROID

Interaction between LABA & Corticosteroids


Corticosteroid Increase b2-receptor synthesis Decrease b2-receptor downregulation Attenuate inflammationmediated b2- receptor uncoupling and dysfunction

LABA LABA increase GR nuclear translocation LABA prolong GR nuclear residency time LABA prime GR for activation byMAPKdependent phosphorylation
Enhance antiinflammatory activity of steroid

% Days
50

Wheezing Medication Low PEFR

40 30 20

10 0

Dust free Bedroom

Control Bedroom

Percentage of days (+ SE) on wich wheezing was noticed, medication was given, and abnormally low peak expiratory flow rate (PEFR) was recorded during 4 week study period

PC20 Histamine Mg/ml >8 8 4 2 1 0.5 0.25 0.12 0.06 0.03 Dust free Bedroom
Initial End of trial

Control Bedroom

Concentration of aerosolized histamine required to reduce the 1-second forced expiratory volume (FEV1) by 20% (PC20 histamine) at start and end of trial period

Conclusions
Asthma prevalence: increase Classifications of childhood asthma: infrequent episodic asthma, frequent episodic asthma, and persistent asthma Longterm management: Inhalation therapy

Você também pode gostar