Management of Severe Asthma and COPD

1. Management of Severe Asthma and COPD PROF. ABDULAZIZ H. ALZEER

2. Learning Objectives Asthma • Definition • Pathophysiology • Factors that triggers Asthma • Manifestation and How To assess the severity of Asthma • Treatment Chronic Obstructive Pulmonary Disease (COPD) • Definition • Risk Factors • Emphysema • Chronic Bronchitis • Treatment and Prevention

4. ASTHMA Definition: Symptom: Cough Wheeze Tightness in the chest Shortness of breath Sometimes nocturnal symptoms • Asthma is a chronic lung disease due to inflammation of the airways resulted into airway obstruction. The obstruction is reversible. • Asthma is the most common chronic disease particularly among children.

5. Pathology of Asthma Inflammation Airway Hyper-responsiveness Airway Obstruction Symptoms of Asthma

6. ASTHMA Smooth muscle contraction Mucosal edema Excessive secretions

7. Asthma Facts about Asthma • Asthma rates have been increasing worldwide for both adults and children, males and females and in different race and ethnicities. • It is estimated that the number of people with asthma worldwide will increase by 25% in the next 15 years.

8. Child and Adult Asthma PrevalenceUnited States, 1980-2007 • Child • Adult Lifetime Current 12-Month Source: National Health Interview Survey; CDC National Center for Health Statistics

9. Asthma Prevalence by SexUnited States, 1980-2007 • Female • Male Lifetime 12-Month Current Source: National Health Interview Survey; CDC National Center for Health Statistics

10. ASTHMA Causes: • Genetic • Atopy • Childhood respiratory infections • Exposure to allergens

11. ASTHMA Asthma Triggers:

12. ASTHMAMANIFESTATION OF SEVERE ASTHMAHistory of - Frequent use of Ventolin inhaler - Previous ICU admission - Use of steroids with no clinical response - Not responding to initial inhalation therapy at ER

13. ASTHMASEVERE ASTHMA:Physical Examination - HR > 115/min - RR > 30/min - Pulsus paradoxus > 10 mmHg - Unable to speak - Cyanosis - Silent chest

14. AsthmaSpirometer

15. Asthma Arterial Blood Gases Acideamia Hypoxiamia Hypercarpia pH PCO2 PO2 1. ↑ ↓ N or ↓ • N N ↓ • ↓ ↑ ↓↓

16. FVC 100 75 50 25 FEV1 > 75% NORMAL = FVC 0 1 2 3 4 5 6 7 8 TIME

17. FVC 100 75 50 25 FEV1 Airway Obstruction = FEV1 < 75% FVC 0 1 2 3 4 5 6 7 8 TIME

18. ASTHMA Poorly controlled asthma leads to: • Increased visits to doctors, hospital ER • Hospitalizations • Limitation in daily activities • Lost work days • Lower quality of life • Death

19. ASTHMA Treatment: Patient/Doctor Relationship • Educate continually • Include the family • Provide information about asthma • Provide training in self-management skills

20. ASTHMA Treatment: Exposure Risk • Reduce exposure to indoor allergens • Avoid tobacco smoke • Avoid vehicle emission • Identify irritants in the workplace

21. ASTHMA Treatment - Inhaled corticosteroids - Long-acting beta2-agonists - Leukotrienes modifiers • Takes daily over long period of time • Used to reduced inflammation, relaxed airway muscles and improve symptoms and lung function

22. Asthma Quick Reliever Used in acute attacks Short acting beta2- agonists Begins to work immediately and peaks at 5-10 minutes

23. AsthmaInhalers and Spacers Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.

24. AsthmaNebulizers • Machine produces a mist of medication • Used for small children or for severe asthma • No evidence that it is more effective than an inhaler used with spacers

25. AsthmaInhaled Corticosteroids • Main stay treatment of asthma • Reduce airway inflammation

26. Asthma Anti- Ig E • For treatment of moderate to severe allergic asthma • For treatment of those who do not respond to high dose of corticosteroids

27. ASTHMA Treatment of Acute Attack of Asthma: - O2 Supplementation - Inhaled Ventolin -Inhaled steroids - Inhaled Atrovent - IV Steroids For severe cases consider: - IV Mg SO4 - Heliox - BiPAP - Mechanical Ventilation – for those who do not respond the above treatments.

28. ASTHMANon-invasive Mechanical Ventilation Treatment

30. Chronic Obstructive Pulmonary Disease (COPD) • Limitation of expiratory flow • Chronic progressive disease • Associated with airway inflammation • Generally irreversible airflow obstruction • Related to smoking

31. Chronic Obstructive Pulmonary Disease (COPD) • Emphysema • Chronic bronchitis • Small airway disease

32. COPD COPD Facts: • COPD is the 4th leading cause of death in the United States • COPD has higher mortality rate than asthma • Leading cause of hospitalization in the US • 2nd leading cause of disability

33. COPD COPD Risk Factors • Smoking: most common cause • Environmental exposure - chemicals. Dust, fumes - second hand smoke • Alpha-1 anti-trypsin (AAT) deficiency

34. Chronic Obstructive Pulmonary Disease (COPD)

35. COPD Alpha 1 Anti-Trypsin (AAT) - is a serine protease inhibitors • Inhibit neutrophil elastase which break down elastin • Synthesized and secreted by hepatocytes • PiZZ phenotype is associated with low plasma concentration of AAT i.e. associated with development of emphysema

36. Emphysema

37. Emphysema

38. Emphysema

39. Emphysema

40. Emphysema

41. Emphysema

42. Chronic Bronchitis Definition • Cough for 3 months in a year for 2 consecutive year

43. Chronic Bronchitis

44. Chronic Bronchitis

45. COPD Clinical Picture • Dyspnea-progressive • Cough with or without expectoration • Wheezing • Loss of weight • Hypercapnia>changes in central nervous system • Barrel chest

46. COPD

47. PURSED LIP BREATHING

48. COPD COPD Treatment • Inhalers (bronchodilators) • Anti-inflammatory medications • Anti-cholinergic • Theophylline therapy • Oxygen therapy • Antibiotics • Pulmonary rehabilitation • Lifestyle changes - give up smoking • BiPAP Therapy for severe patients

49. COPD Treatment • Ventolin nebulization • Steroid inhalation • Atrovent inhalation • Systemic steroid • Non-invasive mechanical ventilation if the above measures were not effective.

50. COPD