Pathophysiology of Asthma / COPD

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Asthma / COPD

Asthma – Diffuse airway inflammation caused by triggering stimuli resulting in partially or completely reversible bronchoconstriction.

COPD – Partially reversible airflow limitation caused by inflammatory response to inhaled toxins, often cigarette smoke, in addition sometimes respiratory insufficiency and complications such as pulmonary hypertension, respiratory infection and weight loss

Check for symptoms:

  • Dyspnea(shortness of breath)
  • Chest tightening
  • Audible wheezing
  • Cough

COPD:

  • Increased expiratory phase of breathing
  • Decreased heart and lung sounds
  • Weight loss

 Intermittent Asthma – short acting beta 2 agonists

Mild persistent Asthma – low dose inhaled corticosteroids or Theophylline or Montelukast.

Moderate persistent Asthma – medium dose inhaled corticosteroids or low dose inhaled corticosteroids + long acting beta 2 agonists or low dose inhaled corticosteroids + Theophylline

Severe persistent Asthma  – high dose inhaled corticosteroids + long acting beta 2 agonista later if it continues oral corticosteroids or

Omalizumab – used rarely to treat severe condition but under expert  physician continuously monitoring symptoms for anaphylactic shock, every time the medicine is administered.

Drug and Dose:     

SA Beta 2 agonists

 

Albuterol

Inhaler – 90 mcg / puff, 2 puffs every 4 – 6 hrs as needed and 2 puffs before exercise

Nebulizer – children below 5 yrs – 0.63 to 2.5 mg in 3 ml saline every 4 – 6 hrs as needed

                    children above 5 yrs – 1.25 to 2.5 mg in 3 ml saline every 4 – 6 hrs as needed

                  adults – 1.25 to 5 mg in 3 ml saline every 4 – 6 hrs as needed

Levalbuterol

Inhaler – 45 mcg / puff, 2 puffs every 4 -6 hrs as needed

Nebulizer – 0.31 to 1.25 mg in 3 ml every 6 – 8 hrs as needed

Pirbuterol

MDI – 200 mcg / puff, 1 – 2 puffs every 4 – 6 hrs as needed

LA Beta 2 agonists – Not be used as monotherapy

Salmeterol

Inhaler — 21 to 50 mcg / puff, 1 – 2 puffs every 12 hrs

Anticholinergics

Ipratropium (SA)

MDI – 18mcg / puff, 2 puffs every 6 hrs as needed

Nebulizer – 500 mcg (0.02%) solution, 500 mcg every 6 – 8 hrs as needed

Tiotropium (LA)

DPI – 18mcg / capsule, 1 capsule / day.

 

Corticosteroids

Beclomethasone – MDI – 40 – 80 mcg / puff, 1 – 2 puffs every 12 hrs

Budesonide

DPI – 90 or 180 mcg / inhalation, 360 mcg twice a day

Nebulizer – 0.5 mg / day or 0.25 mg twice a day for children below 8 yrs, not indicated for adults

Fluticasone

MDI – 44,110,220 mcg / inhalation, children – 88 – 176 mcg twice a day, adults – 88 – 220 mcg twice a day

DPI – 50, 100, 250 mcg / inhalation, children – 50 mcg twice a day, adults – 100 – 250 mcg twice a day

Mometasone

DPI – 110 or 220 mcg / inhalation, children – 110 mcg once a day in evening, adults – 220 mcg once a day in evening

Oral:

Methylprednisolone – 2,4,8,16,32 mg tablets

Prednisolone – 5 mg tablets or 5 mg / 5 ml or 15 mg / 5 ml solution

Prednisone – 1,2.5, 5, 10, 20, 50 mg tablets or 5 mg / ml or 5mg / 5ml solution

children – 1 – 2 mg / kg per day for 3 – 10 days, adults – 7.5 – 60 mg / day in the morning or every other morning for Prednisolone and for Prednisone – 40 – 60 mg once a day or 20 – 30 mg twice a day

Combination drugs

Ipratropium / Albuterol – 2 puffs 4 times a day or 3 ml vial 4 times a day

Fluticasone / Salmeterol – 1 inhalation twice a day

Budesonide / Formoterol – 2 inhalations twice a day

Mometasone / Formoterol – 2 inhalations twice a day

 

Leukotriene modifiers

Montelukast – 4, 5, 10 mg tablets, once a day in the evening

Zafirlukast – 10 , 20 mg tablets, once a day in the evening

 

Methylxanthines

Theophylline – 100, 200, 300, 400 mg ER capsules, 100, 200, 300, 400, 600 mg ER Tablets, 80 mg / 15 ml Elixir, 10 mg / kg / day up to 600 mg per day

Antibiotic therapy for COPD patients with purulent sputum – 10 – 14 days

Long term Oxygen therapy for COPD patients who have Pa02 less than 55 mm of Hg

Counselling on side effects:

Beta 2 agonists – dizziness, headache, palpitations, tachycardia

Leukotriene antagonists – headaches, GI disturbances, sleep disorders

Corticosteroids – decreased ability to respond, physical stress, fatigue, joint pains, muscle tenderness, severe withdrawal syndrome, susceptible to infections, GI tract problems(ulcers), thinning of bones, weight gain, insomnia, mood changes, elevated bp, fluid restriction, elevated sugar, can cause glaucoma, worsen cataract condition, atherosclerosis, aseptic necrosis(death of parts of bone). Elderly patients using corticosteroids having risk factors for osteoporosis must use calcium and vitamin D supplements.

Treat asthma aggressively during pregnancy
  • Aspirin induced asthma – Avoid use of NSAIDS
  •  
  • Controlling triggering factors in Asthma – It is important to control triggering factors
  • Use of synthetic fiber pillows, impermeable mattress covers, frequent washing of bed sheets / pillow covers with hot water
  • Upholstered furniture, soft toys, carpets should be removed
  • Dehumidifiers should be use in basements and house cleaning
  • Aspirin induced should use paracetamol,choline magnesium salicylate etc.

 

Environmental factors for Asthma

  • Avoid exposure to allergens (dust, mite, cockroach, pets)
  • Diet low in vitamin C,E and omega 3 fatty acids
  • Obesity
  • Perinatal factors (young mothers, poor maternal nutrition, premature birth, low birth weight, lack of breast feeding)

 

Other factors:

  • Infections, cold viruses
  • Exercises – specially in cold and dry environment
  • Inhaled irritants – smoke, air pollution
  • Emotions – anxiety, anger, excitement
  • Aspirin – severe asthma upto 30% in older patients
  • GERD induces asthma because of bronchoconstriction

 

Counselling on diet,exercise,lifestyle management:

  • Eat food rich in vitamin C, E, Omega 3 fatty acids
  • Bell Pepper, Guava, Citrus fruits, Papaya, Strawberries for vitamin C
  • Tofu, Spinach, Nuts, Sunflower seeds, Fish for vitamin E
  • Flax seeds, Walnuts, Fish, Tofu, Soybean for Omega 3 fatty acids.

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