ASTHMA

( ID:131021,131036,131037,131039,131040 )

Definition:
Asthma is a chronic inflammatory disorder of the airways. It is defined by the history of
respiratory symptoms such as wheezing, shortness of breath, chest tightness and cough that vary
over time and in intensity, together with variable expiratory airflow limitation

“Asthma” is an ancient Greek word meaning “short breath, panting.”

Asthma is characterized by:

 Airway inflammation: The airway lining becomesred, swollen, and narrow.

 Airway obstruction: The muscles encircling the airway tighten causing the airway to
narrow making it difficult to get air in and out of the lungs.
 Airway hyper-responsiveness: The muscles encircling the airway respond more quickly
and vigorously to small amounts of allergens and irritants.

Asthma triggers:
Things that can cause an asthma attack are referred to as “triggers”.

1. Extrinsic (allergic) triggers:

 Dust mites
 Mould
 Certain foods
 Animal dander
 Pollen
  Smoke
2. Intrinsic(non allergic)triggers:
 Exercise
 Heart burn/ acid reflux
 Infections
 Cold or humid air
 Intense emotion(Ex stress)
 Medications(Ex aspirin)
 Hormones
 Air pollution

Causes of asthma:
Doctors have identified the two main conditions that cause asthma symptoms: inflammation and
airway constriction.

1. Inflammation

With asthma, the inside walls of the airways are swollen, or inflamed. This inflammation makes
the air passages particularly sensitive to irritants and asthma triggers. The swelling narrows the
air passages, making it difficult for air to pass through the airways. This makes it hard to breathe
normally.

2. Airway constriction

When the airways come into contact with certain asthma triggers, the muscles around the
airways tighten. This causes the air passages to become even narrower. It also causes you to have
a tight feeling in the chest. Some say it feels like a rope is being tightened around your chest.
Mucus can get lodged in the narrowed airways, causing more trouble with breathing.

Types of asthma:
According to pathophysiology asthma can be classified into following categories. They are-

1. Allergic asthma:

 This type occurs when an allergy sets off an asthma flare up. Mold, roaches, pollens and
pet dander are common allergies but the list can be endless.  Food sensitivities may also
 play a role. “I think food can have a lot to do with it when it comes to the toxic burden
that you put in your body,” says Pescatore.

 Pescatore explains there is a strong correlation between casein, the protein in milk and
cheese that may trigger asthma. Gluten, yeast and sugar may also be culprits. “I always
look for the non toxic approach first so I have people do food elimination diets and a food
sensitivity test,” says Pescatore.

 “Most of the time we treat this type by finding out what patient’s are allergic to first, so
they know what they should avoid,” says Lee. Patients may be prescribed inhaled
corticosteroids depending on the severity of their asthma.

2. Asthma without allergies

 People may also have asthma not triggered by allergies. Usually an upper respiratory
infection (cold, flu, and rhinovirus) sets off their asthma. As soon as cold or flu
symptoms appear patients are typically prescribed a short course of inhaled
corticosteroids for 10-14 days.

 Pescatore has patients eliminate known allergies, any food sensitivities and eat a clean
diet of low glycemic index protein, fruits, vegetables and nuts to see if this makes a
difference. “Anybody who has asthma has an inflammatory condition,” says Pescatore.
“If youdecrease inflammation in the body, you decrease your body’s need to ‘act out’ so
to speak. When there is less inflammation around there is less need for your bronchials to
constrict and your mast cells to activate and all of the things that occur during an asthma
attack.”

3. Aspirin Exacerbated Respiratory Disease (AERD)

 This type is triggered by aspirin. Patients may have nasal polyps, rhinitis, sneezing and a
runny nose, and a history of aspirin sensitivity. When they take aspirin, they develop
sneezing and a stuffy nose, which leads to wheezing and difficulty breathing. “If this type
of asthma is severe enough, we actually recommend aspirin desensitization. The body is
desensitized with incremental doses of aspirin usually done in a hospital setting,” says
Lee. Once people tolerate the full dose of aspirin they take a daily maintenance dose,
which has been shown to help with polyps, allergies and asthma.

4. Exercise induced asthma

 For these asthmatics, any type of physical exertion or sports leads to coughing, difficulty
breathing and chest tightness that improves when they stop the exertion. Typical
treatment is an inhaled broncodilator medication to open their airway taken about fifteen
minutes before exercise.
  “There are multiple studies that say taking 2000 mg of vitamin C before exercise can
relieve exercise induced asthma,” says Pescatore.  Some folks also have cold weather
induced asthma. Cold air can be a lung irritant just like perfume or cigarette smoke. This
generally occurs in winter.

5. Cough variant

 Cough variant is asthma that is characterized by a dry hacking cough. It can occur while
awake or asleep and affect both adults and children. Patients usually respond well to
inhaled corticosteroids. Vitamin D has also been shown to improve asthma. Studies show
there is less incidence of asthma in the south, which may be related to people having less
sun exposure and lower vitamin D levels in northern climates.

6. Occupational asthma

 Occupational asthma occurs when something on the job sets off an asthma attack. Irritant
induced asthma is usually from smoke or inhaled irritants like chlorine. It’s not related to
an allergy; the irritant is inhaled and triggers an attack.

 In occupations that deal with chemicals like paint or lab animals like rats or mice,
patients may also be allergic to their trigger. They must find out exactly what sets off
their symptoms and try to avoid it. If you can’t get away from your trigger, you may have
to use a corticosteroid inhaler to ease symptoms. Pescatore also likes vitamin A, which
has been shown to help get rid of the mucus in the respiratory tract, which can be an
irritant.

 He also likes Pycnogenol. The pine tree bark extract is an anti-inflammatory

and antioxidantthat clinical research shows helps to open the bronchial tubes and reduces
asthma symptoms.

 While corticosteroids and bronchodilators are often necessary in the treatment of asthma,
there are many things that can help ease symptoms and prevent the various types of
asthma attacks including learning your triggers, finding out what you’re allergic to,
discovering food sensitivities, trying vitamins and herbal supplements, as well as lifestyle
changes such as eating a healthier diet, removing shoes indoors and using a home air
filter.

Besides asthma can be classified as-

1. Acute asthma: presence of active symptoms from airway obstruction or inflammation.

2. Chronic asthma: Absence of extended periods free of symptoms without treatment.
Pathophysiology of asthma:

Key:

o Th= T helper cell.

o IL= Interleukin.
o IgE= Immunoglobulin E.

Signs &symptoms:
Asthma symptoms vary from person to person. You may have infrequent asthma attacks, have
symptoms only at certain times — such as when exercising — or have symptoms all the time.
Asthma signs and symptoms include:

 Shortness of breath
 Chest tightness or pain
 Trouble sleeping caused by shortness of breath, coughing or wheezing
 A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in
children)
 Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or
the flu

For some people, asthma signs and symptoms flare up in certain situations:

 Exercise-induced asthma, which may be worse when the air is cold and dry
 Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or
dust
 Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores,
cockroach waste or particles of skin and dried saliva shed by pets (pet dander)

 Most children with asthma have symptoms before they turn 5. In very young
children, it may be hard for parents, and even doctors, to recognize that the
symptoms are due to asthma. The bronchial tubes in infants, toddlers and
preschoolers are already small and narrow, and head colds, chest colds and other
illnesses can inflame these airways, making them even smaller and more irritated.
 The symptoms of pediatric asthma can range from a nagging cough that lingers for
days or weeks to sudden and scary breathing emergencies.
Risk factors:
There are a number of factors thought to increase the risks of developing asthma. They include
the following.

 Family history
If one of your parents has asthma, then you have a greater risk of developing it.

 Gender and age

Asthma is more common in children than adults. Boys are more likely to develop asthma
than girls. Risks are equal for men and women for adult-onset asthma.

 Allergies
Sensitivity to allergens is often an accurate predictor of your potential to develop asthma.
These allergens often include:
o dust
o pet dander
o mold
o toxic chemicals

Allergens can trigger asthma attacks after you develop asthma.

 Smoking
Cigarette smoke irritates the airways. Smokers have a high risk of asthma. Those whose
mothers smoked during pregnancy or who were exposed to secondhand smoke are also
more likely to have asthma.
 Air pollution
This is the main component of smog, or ozone. Constant exposure to air pollution raises
the risk for asthma. Those who grew up or live in urban areas have a higher risk for
asthma.
 Obesity
Children and adults who are overweight or obese are at a greater risk of asthma. Although
the reasons are unclear, some experts point to low-grade inflammation in the body that
occurs with extra weight.
  Viral respiratory infections
Respiratory problems during infancy and childhood can cause wheezing. Some children
who experience viral respiratory infections go on to have chronic asthma.

There are other factors that are also responsible for increasing asthma. These include:

 Exposure to exhaust fumes or other types of pollution

 Exposure to occupational triggers, such as chemicals used in farming, hairdressing and
manufacturing
 Have had a serious asthma attack in the past
 Low levels of vitamin D
 Being born in the winter months
 Antibiotic use in the first year of life
 Eating a lot of fast food
 Regular acetaminophen use
 Ozone exposure. Ozone is a major component of smog that increases traditional asthma

Management:

Pharmacological treatment:

1. Long-term control medications:

Many people with asthma need to take long-term control medications daily, even when they
don't have symptoms. There are several types of long-term control medications, including the
following:

 Inhaled corticosteroids:

These anti-inflammatory drugs are the most effective and commonly used long-term control
medications for asthma. They reduce swelling and tightening in your airways. You may need to
use these medications for several months before you get their maximum benefit.

Inhaled corticosteroids include:

 Fluticasone (Flovent HFA)

  Budesonide (PulmicortFlexhaler)
 Mometasone (AsmanexTwisthaler)
 Beclomethasone (QvarRediHaler)
 Ciclesonide (Alvesco)

Inhaled corticosteroids don't generally cause serious side effects. When side effects occur, they
can include mouth and throat irritation and oral yeast infections. If you're using a metered dose
inhaler, use a spacer and rinse your mouth with water after each use to reduce the amount of drug
remaining in your mouth.

 Leukotriene modifiers:

These medications block the effects of leukotrienes, immune system chemicals that cause asthma
symptoms. Leukotriene modifiers can help prevent symptoms for up to 24 hours. Examples
include:

 Montelukast (Singulair)
 Zafirlukast (Accolate)
 Zileuton (Zyflo)

In rare cases, montelukast is linked to psychological reactions, such as agitation, aggression,

hallucinations, depression and suicidal thinking.

 Long-acting beta agonists (LABAs):

These bronchodilator medications open airways and reduce swelling for at least 12 hours.
They're used on a regular schedule to control moderate to severe asthma and to prevent nighttime
symptoms. Although they're effective, they've been linked to severe asthma attacks. For this
reason, LABAs are taken only in combination with an inhaled corticosteroid.

The most commonly used LABA for asthma is

 salmeterol (Serevent)

 formoterol

 Theophylline:
Theophylline relaxes the airways and decreases the lungs' response to irritants. It can be helpful
for nighttime asthma symptom. Potential side effects of theophylline include insomnia and
gastroesophageal reflux.

 Combination inhalers: Corticosteroids and long-acting beta agonists:

Some inhaled asthma medication combinations contain both a corticosteroid and a

bronchodilator:

 Fluticasone and salmeterol (AdvairDiskus)

 Budesonide and formoterol (Symbicort)
 Mometasone and formoterol (Dulera)
 Fluticasone and vilanterol (Breo)

2. Quick-relief medications:

Some people use a quick-relief inhaler before exercise to help prevent shortness of breath and
other asthma symptoms. Possible side effects include jitteriness and palpitations.Quick-relief
medications include:

 Short acting beta agonist: These quick relief bronchodilators act within minutes to
rapidly ease symptoms during an asthma attack-

 Albuterol
 Levalbuterol

However, most people with persistent asthma also need an inhaled corticosteroid or other
long-term control medication.If you need to use your inhaler more often than your doctor
recommends, your asthma is not under control — and you may be increasing your risk of a
serious asthma attack.

 Ipratropium:

Ipratropium (Atrovent HFA) is a short-acting bronchodilator that's usually prescribed for

emphysema or chronic bronchitis, but is sometimes used to treat asthma attacks. It may be used
either with or as an alternative to short-acting beta agonists.

 Oral corticosteroids & intravenous cortecosteroids:

These medications may be taken to treat severe asthma attacks. They can cause bothersome
short-term side effects and more-serious side effects if they're taken for a long period. Examples
include:

 Prednisones
 Methylprednisolone

Long-term use of these medications can cause side effects including cataracts, thinning bones
(osteoporosis), muscle weakness, decreased resistance to infection, high blood pressure and
reduced growth in children.

Non pharmacological treatment:

1. Avoid asthma triggers

2. prevent mold spores

3. covering nose & mouth

4. get regular exercise

5. maintain a healthy weight

Mechanism of action:
Salmetrol:

salmeterol is a direct acting sympathomimetic which relaxes bronchial smooth muscle by its
selective action on beta 2 receptors with little effect on heart failure.

salbutamol:

salbutamol

stimulates b2 receptors in bronchus

stimulation of adenylate cyclase

 Increase cAMP Production

Bronchodilation

Montelucast :

Montelucast

selective leukotrine receptor antagonist

blocks the effects of cysteinyl leukotrienes in the airways

Bronchodilation

Theophylline:

Theophylline

blocks phosphodiesterase

increases cAMP tissue concentration

causing bronchodilation,diuresis,CNS,cardiac stimulation

Prevention:
While there's no way to prevent asthma, by working together, you and your doctor can design a
step-by-step plan for living with your condition and preventing asthma attacks.

 Follow asthma action plan:

 With your doctor and health care team, write a detailed plan for taking
medications and managing an asthma attack. Then be sure to follow your plan.
 Asthma is an ongoing condition that needs regular monitoring and treatment.
Taking control of your treatment can make you feel more in control of your life in
general.

 Get vaccinated for influenza and pneumonia:

  Staying current with vaccinations can prevent flu and pneumonia from triggering
asthma flare-ups.

 Identify and avoid asthma triggers:

 A number of outdoor allergens and irritants — ranging from pollen and mold to
cold air and air pollution — can trigger asthma attacks
 Monitor your breathing:
 You may learn to recognize warning signs of an impending attack, such as slight
coughing, wheezing or shortness of breath. But because your lung function may
decrease before you notice any signs or symptoms, regularly measure and record
your peak airflow with a home peak flow meter.

 Identify and treat attacks early:

 If you act quickly, you're less likely to have a severe attack. You also won't need
as much medication to control your symptoms.

 Take your medication as prescribed:

 Just because your asthma seems to be improving, don't change anything without
first talking to your doctor. It's a good idea to bring your medications with you to
each doctor visit, so your doctor can double-check that you're using your
medications correctly and taking the right dose.

 Pay attention to increasing quick-relief inhaler use:

 If you find yourself relying on your quick-relief inhaler, such as albuterol, your
asthma isn't under control. See your doctor about adjusting your treatment.

Market preparation:
Generic name Brand name
Montelucast(4mg,5mg,10mg) montene (square
pharma ),montex(Ibn sina pharma)
Zafnil(general
Zafirlukast(20mg) pharma),Zaft(Renata pharma)

Salmetrol(25mg) Salmete HFA (square pharma)

salbutamol(2mg/5mg,4mg,2.4mg/5mg) windel(incepta
pharma),Azmasol(Beximco
pharma)Brodil HFA(ACI limited)

Levosalbutamo(1mg,2mg,1mg/5ml,50mcg) Asmolex
L(aristopharma),Lavair(general
pharma)
Levostar(square pharma),Livodel
(popular pharma)
Theophylline(400mg,250mg, 2oo,300mg,120mg/5ml) Thenglate (Acme
laboratories),Theofast CR(Globe
pharma)
Prednisolone(10mg,20mg,5mg,500mg,120mg,1gm/100ml Pred(Eskayef
) pharma),Predflam(general
pharma)
Ipratropium Bromide+ Combair HFA(ACI
Salbutamol(100mcg+20mcg/puff,20mcg+100mcg/puff) Pharma),Iprasol(Beximco
pharma),Sulprex HFA(Square
pharma)
Fluticasone furate nasal prep (27.5 mcg) Flutica ( Aristo pharma)