Asthma and COPD

ASTHMA AND COPD
DR. SABRINA VILBRUN
BASED ON GINA GUIDELINES AND GOLD

DEFINITION OF ASTHMA
• Asthma is a condition characterized by chronic airway inflammation

• History of respiratory symptoms such as wheeze, SOB, chest tightness and cough that vary
over time and in intensity together with variable expiratory airflow limitation
• Variations often triggered by factors such as exercise, allergen and irritant exposure, weather
changes or viral respiratory infections.
• Symptoms and airflow limitation often resolve spontaneously or in response to medication.
• Sometimes absent for weeks or months at a time
DEFINITION OF ASTHMA
• Episodic flare-ups (exacerbations). May be lifethreatening

• Associated with airway hyperresponsiveness to direct/indirect stimuli and with chronic
airway inflammation
CLINICAL PHENOTYPES OF ASTHMA
• Allergic asthma: usually starts in childhood, associated with a PH or FH of allergic disease

such as eczema, allergic rhinitis, food/drug allergy → responds well to ICS treatment.
• Non-allergic asthma: Not associated with allergy → less short-term response to ICS.
• Adult-onset (late-onset) asthma: present for the first time in adult life (M/C women). Tend
to be non-allergic, often require higher doses of ICS. Occupational asthma should be ruled
out.
• Asthma with persistent airflow limitation: Longstanding asthma: persistent or
incompletely reversible. (may be due to airway wall remodeling)
PATHOPHYSIOLOGY OF ASTHMA
• Airway hyperresponsiveness- crutial feature of asthma

• Cascade of inflammatory events involving IgE antibodies that respond to certain
environmental triggers
• Cytokines released cause contraction of smooth muscle cells leading to airway tightening.
• Results in intermittent airflow obstruction requiring increased work of breathing
PATHOPHYSIOLOGY OF ASTHMA
SYMPTOMS AND SIGNS OF ASTHMA
Occur in episodes/attacks. May be mild at first and develop into more serious symptoms
• Shortness of breath
• Coughing/urge to cough
• Wheezing
• Chest tightness
SIGNS AND SYMPTOMS
• Wheezing may be absent in severe asthma exacerbations: Silent chest (due to severely
reduced airflow.
• Presence of other physical signs of respiratory failure
MAKING THE DIAGNOSIS
↑ probability that patient has asthma:

• Patient experience more than 1 of these symptoms (wheeze, SOB, cough, chest tightness)
• Worse at night or in the early morning
• Vary over time and in intensity
• Triggered by viral infections, exercise, allergen exposure, changes in weather, irritants
↓ probability that respiratory symtoms are due to asthma

• Isolated cough with no other respiratory symptoms
• Chronic production of sputum
• Shortness of breath associated with dizziness, light headedness or peripheral tingling
• Chest pain
DIFFERENTIAL DIAGNOSIS
• Wheezing ≠ asthma
• Inducible laryngeal obstruction
• Chronic obstructive pulmonary disease (COPD)
• Respiratory infections
• Tracheomalacia
• Inhaled foreign body
Crackles, crepitations and inspiratory wheezing are not features of asthma.
DRUGS USED IN ASTHMA/COPD
• Bronchodilators
• Anti-inflammatory agents
• Oxygen (↓ SPO2)
BRONCHODILATORS
• B2 Agonists
1. SABA (Salbutamol, Terbutaline)
2. LABA (Salmeterol, Formoterol)
• Anticholinergics
1. SAMA (Ipratropium Bromide)
2. LAMA (Tiotropium Bromide)
• Methylxanthines (Theophylline, Aminophylline)
ANTI-INFLAMMATORY AGENTS
• Corticosteroids (Inhaled or systemic)

1. Inhaled corticosteroids (Beclomethasone dipropionate, budesonide, fluticasone)
2. Systemic corticosteroids (Hydrocortisone and prednisolone)
• Leukotriene antagonist (Montelukast)
SIDE EFFECTS OF DRUGS USED IN
ASTHMA/COPD
• B2 Agonists : tremors, tachycardia, palpitations, arrythmia, headache. Hypokalemia may
occur at high doses as it stimulates the uptake of K+ into cells.
• Anticholinergics : dry mouth, blurred vision, tachycardia, constipation, urinary retention,
mydriasis
• Methylxanthines: Nausea, tachycardia, palpitations, arrythmias
• ICS: Local oropharyngeal candidiasis
MANAGEMENT OF ASTHMA
To prevent exacerbations and control symptoms
CATEGORIES OF ASTHMA MEDICATIONS
• Controller medications: contain ICS and used to reduce airway inflammation, control
symptoms and reduce future risk of exacerbations and decline in lung function.
(Recommended: Low dose ICS-formoterol)
• Reliever medications: As-needed relief of breakthrough symptoms (ICS-formoterol or
SABA as-needed)
Studies have shown that over-use of SABA (dispensing 3 or more 200-dose canisters in a
year) increases the risk of asthma exacerbations
Goal of treatment : eliminate the need for SABA reliever.
UNCONTROLLED SYMPTOMS/EXACERBATIONS
• Incorrect inhaler technique

• Poor adherence
• Persistent exposure at home/work
• Exposure to medications such as Beta-blockers or NSAIDs
• Incorrect diagnosis
• Commorbidities that may contribute to respiratory symptoms and poor quality of life
ACUTE EXACERBATIONS OF ASTHMA
MILD MODERATE SEVERE LIFE-

THREATENING
• Speaking in full • Speaking in a few • Moderate to severe • Drowsy
sentences words use of accessorry • Confused
• Mild to no use of • Mild to moderate muscles • Silent chest
accessory muscles use of accessory • Altered mental
• Mild expiratory muscles status
wheezing only • Moderate to severe • SPO2 < 90%
• Vital signs WNL wheezing • ↑ RR >120
• SPO2 >90% • SPO2 >90% • ↑ HR
• ↑ RR
• ↑ HR
MANAGEMENT OF ACUTE EXACERBATIONS OF
ASTHMA
• Routine use of antibiotics in the treatment of acute asthma exacerbations in not
recommended unless there is strong evidence of lung infection (e.g. Fever, purulent
sputum or radiographic evidence of pneumonia)
• Clinical status and oxygen saturation should be reassessed frequently with further
management titrated according to patient’s response.
• To reduce risk of relapse, prescribe at least a 5-7 day course of OCS for adults
(prednisolone 40-50 mg/day)
ASTHMA AND COPD
• Symptoms may be similar with overlapping diagnostic criteria

• Extremely important differences in evidence-based treatment recommendations for
asthma and COPD
• Treatment with LABA and/or LAMA alone (without ICS) is recommended as initial
treatment in COPD but contraindicated in asthma due to the risk of severe exacerbations
and death.
• High does ICS should not be used in COPD due to the risk of pneumonia.
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD)
DEFINITION OF COPD (GOLD 2021)
• Common and preventable disease characterized by persistent respiratory symptoms and

airflow limitation that is secondary to airway and alveolar abnormalities
• Usually caused by significant exposure to noxious particles or gases and influenced by
host factors including abnormal lung development
• Most common symptoms include dyspnea, cough and/or sputum production and recurrent
LRTIs
CAUSES OF COPD
• Tobacco smoking: associated with a greater COPD mortality rate. Also includes other
types of tobacco such as pipe, cigar, water pipe and marijuana as well as environmental
tobacco smoke.
• Indoor air pollution: burning of wood and other fuels used for cooking and heating in
poorly vented dwellings. Particularly affects women in developing countries.
• Occupational exposure: including organic and inorganic dusts, chemical agents and
fumes
• Genetic factors: severe hereditary deficiency of alpha-1 antitrypsin
DIAGNOSIS OF COPD
• Spirometry is required to make the diagnosis: presence of a post-bronchodilator

FEV1/FVC < 0.70 (confirming presence of persistent airflow limitation)
• COPD should be considered in patients with dyspnea, chronic cough or sputum
production and/or a history of exposure of risk factors for the disease.
• CXR not useful in establishing a diagnosis in COPD but helps to exclude alternative
diagnoses such as concomitant respiratory diseases and cardiac diseases (cardiomegaly)
HYPERINFLATED CHEST
• Flattened hemidiaphragm
• More than 6 anterior or
10 posterior ribs
• Hyperlucent lungs (less
bronchovascular markings
per unit area)
KEY INDICATORS TO CONSIDER DIAGNOSIS OF
COPD
• Dyspnea that is progressive over time, worse with exercise and persistent.
• Chronic cough: may be intermittent and may be unproductive + recurrent wheezing
• Any pattern of chronic sputum production
• Recurrent respiratory tract infections
• History of risk factors mentionned earlier
• Family history of COPD
DIFFERENTIAL DIAGNOSIS OF COPD
• Modifidies British Medical Research Council (mMRC) questionaire is no longer adequate

for assessment of symptoms.
• COPD Assessment Test (CAT) now recommended for a comprehensive assessment of
symptoms.
MANAGEMENT OF COPD
• Identification and reduction of exposure to risk factors

• Smoking cessation- referral to smoking cessation clinic
• Physical activity is recommended for all group of patients
• Flu and pneumococcal vaccination
• Initiation of treatment according to individualised assessment of symptoms and
exacerbation risk following the ABCD assessment scheme as follows:
MANAGEMENT OF EXACERBATIONS
• Exacerbations may be precipitated by several factors. M/C respiratory tract infections

• DDx: pneumonia, pneumothorax, pleural effusion, pulmonary embolism, pulmonary
edema due to cardiac related conditions, cardiac arrythmias
• SABA (salbutamol) with or without SAMA (ipratropium bromide) recommended as
initial bronchodilators to treat acute exacerbations
• Systemic corticosteroids can improve lung function, oxygenation and shorten recovery
and hospitalisation. Duration not more than 5-7 days.
MANAGEMENT OF EXACERBATIONS
• Antibiotics (when indicated) can shorten recovery time, reduce risk of relapse. Not more
than 5-7 days.
• Methylxanthines (theophylline) not recommended due to increased side effect profiles
• Non-invasive mechanical ventilation first mode of ventilation used in COPD in patients
with acute respiratory failure
No respiratory failure Acute respiratory failure : Acute respiratory failure
non-life threatening life threatening
• RR 20-30 bpm • RR: >30 bpm • RR>30 bpm
• No use of accessory muscles • Use of accessory muscles • Use of accessory muscles
• No changes in mental status • No change in mental status • Acute changes in mental
• Hypoxemia improved with • Hypoxemia improved with status
supplemental oxygen supplemental oxygen • Hypoxemia not improved
• No increase in PaCO2 • Presence of hypercarbia with supplemental oxygen
• Hypercarbia
• Presence of acidosis
MANAGEMENT OF SEVERE EXACERBATIONS
• Assess severity of symptoms, obtain CXR, blood gas if possible

• Administer supplemental oxygen, SPO2 monitoring (target SPO2 88-92%)
• Use of combines SABA and anticholinergics (ventolin + atrovent)
• Consider oral corticosteroids
• Consider use of antibiotics
• Consider non-invasive mechanical ventilation
• Monitor fluid balance
• Consider subcut LMWH for thromboembolism prophylaxis
• Identify and treat associated conditions (heart failure, PE, arrythmias)
INDICATIONS FOR INTUBATION
ASTHMA-COPD OVERLAP
• Patients who have persistent airflow limitation together with clinical features that are
consistent with both asthma and COPD.
CLINICAL CASE
CLINICAL CASE
• 83 years old male

• History of cough + yellow sputum, fever, wheezing for 2 days
• Ex-smoker- 10 cigs/day for past 40 years
• Ex chronic alcoholic
• PMH: AF
CLINICAL CASE
• O/E patient was dyspneic

• BP 130/80
• SPO2 on RA was 88%
• Temperature: 39.2 °C
• RS: B/L wheezing + B/L basal crepts
CXR
TREATMENT GIVEN
• Admission
• Oxygen via facemask
• Rocephin 1g BD/ Solumedrol 40mg OD/ Perfalgan 1g TDS/Syr cough expect/Omeprazole
20mg BD
• Neb i ventolin + atrovent
• IV lasix 20mg OD
FBC and U&Es were WNL
CRP: 36.0
Now patient feeling better. SPO2 on RA 93%
RESOURCES
• Global strategy for asthma management and prevention (GINA 2022)

• Global initiative for chronic obstructive lung disease (GOLD 2021)

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ASTHMA AND COPD

DR. SABRINA VILBRUN

BASED ON GINA GUIDELINES AND GOLD

• Asthma is a condition characterized by chronic airway inflammation

• Episodic flare-ups (exacerbations). May be lifethreatening

• Allergic asthma: usually starts in childhood, associated with a PH or FH of allergic disease

• Airway hyperresponsiveness- crutial feature of asthma

↑ probability that patient has asthma:

↓ probability that respiratory symtoms are due to asthma

• Corticosteroids (Inhaled or systemic)

• Incorrect inhaler technique

MILD MODERATE SEVERE LIFE-

• Symptoms may be similar with overlapping diagnostic criteria

• Common and preventable disease characterized by persistent respiratory symptoms and

• Spirometry is required to make the diagnosis: presence of a post-bronchodilator

• Modifidies British Medical Research Council (mMRC) questionaire is no longer adequate

• Identification and reduction of exposure to risk factors

• Exacerbations may be precipitated by several factors. M/C respiratory tract infections

• Assess severity of symptoms, obtain CXR, blood gas if possible

• 83 years old male

• O/E patient was dyspneic

• Global strategy for asthma management and prevention (GINA 2022)

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