Asthma Treatment & Management Guidelines, Symptoms, Classification, Types, Medicine Lecture USMLE

Summary

This video lecture discusses asthma, a chronic respiratory condition marked by reversible airflow obstruction and bronchial inflammation. It covers the triggers, clinical presentation, and diagnosis using pulmonary function tests. The script also explains the classification of asthma and its step-by-step treatment, including the use of inhalers and bronchodilators. Additionally, it addresses general measures, follow-up, and side effects of medications.

Takeaways

• 🌪️ Asthma is a chronic inflammatory disease of the respiratory system characterized by reversible air flow obstruction, bronchial hyper responsiveness, and inflammation.
• 🌿 Extrinsic asthma is allergic in nature, often triggered by allergens like pollens, dust mites, and pet dander, while intrinsic asthma is non-allergic and can be triggered by viral infections or cold air.
• 🚫 Certain medications like beta blockers and NSAIDs can induce asthma symptoms due to their effects on bronchoconstriction.
• 👶 Children exposed to second-hand smoke are at an increased risk of developing asthma.
• 🔊 Clinical presentation of asthma includes symptoms like persistent dry cough, shortness of breath, and chest tightness, with wheezing heard upon auscultation.
• 📈 Spirometry, a type of pulmonary function test, is crucial for diagnosing asthma by measuring forced expiratory volume in one second (FEV1) and forced vital capacity (FVC).
• 🌡 Bronchial provocation tests, though not commonly performed, can provoke bronchoconstriction to confirm asthma diagnosis in patients with normal spirometry results.
• 💊 Treatment for asthma includes short-acting beta agonists (SABA) for rescue and inhaled corticosteroids (ICS) combined with long-acting beta agonists (LABA) for maintenance.
• 📉 Asthma is classified into intermittent, mild persistent, moderate persistent, and severe persistent based on symptom frequency and severity.
• 💉 Oral corticosteroids are reserved for severe persistent asthma that is not controlled with inhaler therapy due to their significant side effects.
• 🛑 Smoking cessation is critical for asthma patients as it can exacerbate symptoms and is a primary preventive measure.

Q & A

What is asthma?

Asthma is a chronic inflammatory disease of the respiratory system characterized by reversible air flow obstruction, bronchial hyper responsiveness, and bronchial inflammation.

What are the key features of asthma?

The key features of asthma include airflow obstruction that is reversible, episodic, and accompanied by hyper responsiveness of bronchi and bronchioles, leading to constriction and inflammation.

How is asthma classified based on triggers?

Asthma is divided into two categories based on triggers: extrinsic asthma, which is mainly allergic, and intrinsic asthma, which is non-allergic and often triggered by viral infections or cold air.

What are common triggers for extrinsic asthma?

Common triggers for extrinsic asthma include allergens like pollens, dust mites, pets, and floor dust.

What is the prognosis for extrinsic asthma?

Extrinsic asthma, also known as allergic asthma, generally has a good prognosis.

What are the clinical presentations of asthma?

Clinical presentations of asthma include persistent dry cough, shortness of breath, chest tightness, and wheezing due to bronchiole constriction.

How is asthma diagnosed?

Asthma is diagnosed through typical clinical features like dry cough, difficulty breathing, chest tightness, and wheezes, along with demonstration of reversible bronchoconstriction through tests like pulmonary function tests (PFTs) and spirometry.

What is the difference between COPD and asthma on spirometry?

Both COPD and asthma can show a decrease in FEV1/FVC ratio on spirometry, but COPD patients usually have a baseline obstruction, whereas asthma patients may have normal spirometry results between attacks.

What is the significance of bronchodilator reversibility test?

The bronchodilator reversibility test is used to differentiate between COPD and asthma. In asthma, there is typically a greater than 12% increase in forced expired volume in the first second (FEV1) after bronchodilator administration, whereas COPD patients show little to no improvement.

How is asthma classified according to the National Asthma Education and Prevention Program?

According to the National Asthma Education and Prevention Program, asthma is classified into intermittent asthma and persistent asthma, with the latter further divided into mild persistent, moderate persistent, and severe persistent asthma based on symptom frequency and severity.

What is the treatment for intermittent asthma?

Intermittent asthma is treated with short-acting beta-agonist (SABA) inhalers as needed for relief, with daily therapy not typically required. However, the 2020 GINA guidelines recommend considering the addition of low-dose inhaled corticosteroids for daily therapy.

What are the potential side effects of inhaled corticosteroids used in asthma treatment?

Potential side effects of inhaled corticosteroids include oral candidiasis, which is why patients are advised to rinse their mouth after use. Other side effects of systemic corticosteroids include diabetes mellitus, cataracts, osteoporosis, and adrenal suppression.

Outlines

00:00

🌬️ Understanding Asthma

The script begins by explaining asthma as a chronic inflammatory disease of the respiratory system. It highlights the features of asthma, including reversible air flow obstruction, bronchial hyper-responsiveness, and inflammation. The triggers for asthma are discussed, dividing asthma into extrinsic (allergic) and intrinsic (non-allergic) types. Extrinsic asthma is often linked to allergies to pollens, dust mites, and pets, while intrinsic asthma can be triggered by viral infections and cold air. The script also touches on how certain medications, like beta blockers and NSAIDs, can induce asthma symptoms. The importance of family history and exposure to second-hand smoke in the development of asthma is also mentioned.

05:00

🔍 Clinical Presentation and Diagnosis

This section delves into the clinical presentation of asthma, such as persistent dry cough, shortness of breath, and chest tightness. It explains the physical signs of asthma, like wheezing and hyper resonance in the lungs. The diagnosis process is outlined, emphasizing the use of pulmonary function tests (PFTs), particularly spirometry, to measure forced expiratory volume in one second (FEV1) and the FEV1/FVC ratio. The script also discusses how asthma can present differently, with some patients having normal lung function tests outside of an attack. Bronchial provocation tests are mentioned as a method to provoke bronchoconstriction for diagnostic purposes, although they are not commonly performed due to risks associated with severe asthma.

10:02

🏥 Differentiating Asthma from COPD

The script addresses how to differentiate asthma from COPD on spirometry results, noting that both conditions can show a decreased FEV1/FVC ratio. It points out that COPD patients typically have a baseline obstruction, whereas asthma patients may have normal lung function between attacks. The use of bronchodilator reversibility tests is introduced as a method to distinguish between the two, where a significant increase in FEV1 after bronchodilator use suggests asthma. The classification of asthma by the National Asthma Education and Prevention Program is also covered, outlining intermittent, mild persistent, moderate persistent, and severe persistent asthma.

15:03

💊 Treatment Approaches for Asthma

This part of the script discusses the treatment of asthma, starting with intermittent asthma and moving through mild, moderate, and severe persistent asthma. It details the use of short-acting beta-agonists (SABA) like albuterol for rescue therapy and the addition of low-dose inhaled corticosteroids for daily therapy in mild persistent asthma. For moderate and severe persistent asthma, the script describes the use of long-acting beta-agonists (LABA) in combination with inhaled corticosteroids, leukotriene receptor antagonists, and long-acting muscarinic antagonists. The importance of patient compliance, proper inhaler technique, and the use of spacers is emphasized. The script also cautions about the side effects of medications used in asthma treatment.

20:05

📈 Managing and Monitoring Asthma

The final section focuses on the management and monitoring of asthma. It stresses the importance of medication review, avoiding allergens, treating comorbidities, and smoking cessation. The use of peak flow meters for patients to monitor their lung function at home is introduced. The script also discusses the importance of follow-up visits to assess symptom frequency and lung function, and the possibility of step-down therapy if the patient is stable. It addresses the inadequate response to treatment, the need for compliance checks, and the proper use of inhalers. The side effects of inhaled corticosteroids and oral corticosteroids are mentioned, along with historical notes on the use of grimald cigarettes, which contained atropine and cannabis, as a treatment for asthma in the past.

Keywords

💡Asthma

Asthma is a chronic inflammatory disease of the respiratory system characterized by reversible air flow obstruction, bronchial hyper-responsiveness, and bronchial inflammation. It is the central theme of the video, which discusses its presentation, diagnosis, and treatment. The script mentions that asthma is episodic and reversible, with symptoms like wheezing and shortness of breath that can be triggered by allergens or viral infections.

💡Reversible Airflow Obstruction

Reversible airflow obstruction refers to the temporary narrowing of the airways that can be reversed with treatment, a key feature of asthma. The script explains that in asthma, the bronchioles constrict, causing difficulty in breathing, which is episodic and reversible, as seen in the comparison of normal bronchioles versus those in asthma.

💡Bronchial Hyper-responsiveness

Bronchial hyper-responsiveness is a state where the bronchi and bronchioles are more sensitive and react strongly to various triggers, leading to constriction. The script mentions that this hyper-responsiveness is a characteristic of asthma, causing the airways to constrict upon exposure to allergens or cold air.

💡Extrinsic Asthma

Extrinsic asthma, also known as allergic asthma, is a type of asthma triggered by allergens such as pollens, dust mites, and pet dander. The script describes it as the main form of allergic asthma, where patients develop bronchial constriction and inflammation upon exposure to these allergens.

💡Intrinsic Asthma

Intrinsic asthma is a non-allergic form of asthma, often triggered by factors like viral infections or cold air. The script explains that unlike extrinsic asthma, intrinsic asthma does not have an allergic basis and is more common in children and individuals with GERD.

💡Pulmonary Function Tests (PFTs)

Pulmonary function tests are diagnostic tools used to measure lung capacity and airflow, which are crucial in diagnosing asthma. The script discusses how PFTs, specifically spirometry, can demonstrate reversible bronchoconstriction by measuring the forced expiratory volume in one second (FEV1) and comparing it to the forced vital capacity (FVC).

💡Spirometry

Spirometry is a type of pulmonary function test that measures how much air a person can exhale, and how quickly they can exhale it. The script describes spirometry as a main test for diagnosing asthma by assessing the FEV1 and the FEV1/FVC ratio, which are indicative of airway obstruction.

💡Bronchodilator

A bronchodilator is a medication that relaxes the muscles in the airways, increasing airflow. The script mentions the use of bronchodilators like albuterol in treating asthma attacks by causing bronchodilation and providing relief from symptoms.

💡Inhaled Corticosteroids

Inhaled corticosteroids are medications used to reduce inflammation in the airways and are a cornerstone of asthma treatment. The script discusses their use in daily therapy for persistent asthma, with examples such as budesonide and fluticasone, to control inflammation and prevent asthma attacks.

💡Status Asthmaticus

Status asthmaticus is a severe and continuous asthma attack that does not respond to initial treatment. The script briefly mentions it in the context of the risks associated with bronchial provocation tests and refers to a separate video detailing its management.

💡Peak Flow Meter

A peak flow meter is a device used to measure the speed of airflow out of the lungs, which can help monitor asthma control. The script advises teaching patients to use a peak flow meter to track their lung function and the effectiveness of their asthma treatment at home.

Highlights

Asthma is a chronic inflammatory disease of the respiratory system characterized by reversible air flow obstruction.

Asthma is divided into extrinsic (allergic) and intrinsic (non-allergic) categories based on triggers.

Extrinsic asthma often has a good prognosis and is associated with a family history of atopy.

Intrinsic asthma can be triggered by viral infections and is often linked to GERD.

Children exposed to second-hand smoke have an increased risk of developing asthma.

Asthma symptoms include persistent dry cough, shortness of breath, and chest tightness.

Pulmonary function tests, specifically spirometry, are crucial for diagnosing asthma.

Asthma diagnosis can be confirmed with a decrease in FEV1/FVC ratio on spirometry.

Bronchial provocation tests can be used to diagnose asthma in patients with normal spirometry results.

Asthma is classified into intermittent, mild persistent, moderate persistent, and severe persistent categories.

Intermittent asthma is characterized by symptoms less than twice a week and no daily activity limitations.

Mild persistent asthma is treated with low-dose inhaled corticosteroids and short-acting beta-agonists.

Moderate persistent asthma requires a combination of inhaled corticosteroids and long-acting beta-agonists.

Severe persistent asthma may necessitate the addition of oral corticosteroids to inhaled therapies.

General measures for asthma patients include medication review, allergen avoidance, and smoking cessation.

Teaching patients the use of peak flow meters can help monitor asthma symptoms at home.

Inhaled corticosteroids can cause oral candidiasis, and patients should rinse their mouths after use.

An interesting historical note is that Grimald cigarettes, containing atropine and cannabis, were once prescribed for asthma.

Transcripts

okay in our video series of pulmonology

lectures in this video we are going to

talk about asthma we are going to

discuss the presentation and diagnosis

of asthma we are going to discuss it how

do you treat a patient of asthma step by

step first of all asthma is a chronic

inflammatory disease of respiratory

system characterized by reversible air

flow obstruction

and bronchial hyper responsiveness and

bronchial inflammation so there are

three main important things that there

is airflow obstruction blood that

airflow obstruction is reversible that

airflow obstruction is episodic and

there is hyper responsiveness of bronchi

and bronchioles so the bronchioles

constrict and there is inflammation of

the bronchioles this is a picture

showing normal bronchioles look at the

normal dilated bronchioles and this is

the picture showing bronchioles in

asthma where they are constricted they

are red they are inflamed and that

happens episodically that is reversible

now coming to the triggers of asthma on

the basis of the triggers of asthma

asthma is divided into two categories

extrinsic and intrinsic asthma extrinsic

asthma is mainly the allergic asthma and

patients are allergic to pollens dust

mites pets floor dust patients whenever

they are exposed to these things they

develop bronchial constriction they

develop inflammation of the bronchi they

get difficulty in breathing they develop

visas in their chest they're allergic to

these things these are the people who

also have a history of atop these people

have members in their family who are

also allergic to many things they have a

family history of etopy and remember

extrinsic asthma allergic asthma has a

good prognosis

the other category includes intrinsic

asthma in intrinsic asthma it is

non-allergic

and most common cause of non-allergic

asthma is viral infection especially in

the children cold air can induce known

allergic or intrinsic asthma exposure to

cold air causes constriction of the

bronchiole inflammation and resulting in

asthma

these patients usually have Gerd asthma

patients are three times more likely to

develop gerd because this acid reflux it

irritates the bronchial Airways when it

irritates the bronchial Airway it causes

constriction

medications like beta blockers NSAIDs

can also cause asthma beta blockers

block The beta2 receptors and they cause

bronchoconstriction that's why we use

beta agonists for the treatment NSAIDs

can also cause bronchoconstriction

NSAIDs cause increase in leukotriene

levels which cause bronchoconstriction

so this is extrinsic asthma which is

allergic intrinsic eczema which is

non-allergic an important point to

remember is that children who have

exposure to second-hand smoke have

increased risk of developing asthma

now coming to the clinical presentation

of asthma whenever a patient with asthma

is exposed to these agents that

triggered asthma they develop persistent

dry cough they develop shortness of

breath they develop chest tightness

because the bronchioles have now

constricted when the bronchioles have

constricted it's difficult for the air

to get out of the lungs it is an

obstructive disease therefore you will

listen to and expiratory weasels there

will be visas at the end of expression

because it is difficult for the air to

get out of the lungs and when it is

difficult for the air to get out of the

lungs air will accumulate in there and

there will be hyper resonance the lungs

will be hyper resonant now this is how

the VZ chest sounds like whenever you

put stethoscope on the chest of a person

who is suffering from asthmatic attack

this is how the chest sounds like

this is not how a normal chest sounds

like these are the whises that are

present in the chest you can put the

stethoscope on your own chest and listen

to the normal breath sounds and then

compare it with this audio these are all

the Visas because it is difficult for

the air to get out of the lungs now

coming to the diagnosis of asthma in the

diagnosis of asthma if the patient's age

is greater than or equal to five years

of age if the patient has typical

clinical features of asthma dry cough

difficulty breathing chest tightness

wheezes and with that there is

demonstration of reversible

bronchoconstriction how do you do that

you do that with tests like pfts

pulmonary function tests are the main

tests for diagnosis of asthma in

pulmonary function test there is a test

called a spirometry in spirometry what

you do is that you ask the patient to

take a full breath and then exhale

through mouth into this device this

device is a part of spirometer and that

spirometer detects that how much a

person can exhale and with which speed

they can exhale now if the patient is

having asthma that patient would not be

able to Exhale air out easily because

there is obstruction because there is

bronchoconstriction so the forced

expiratory volume in the first second it

detects the force expiratory volume in

the first second and that volume of air

that that patient exhales will be less

than a normal person and we also

calculate the ratio of force expiratory

volume 1 with forced vital capacity the

capacity of air that a person can

normally exhale is called as forced

vital capacity and that ratio is also

decreased

so a normal person can exhale air easily

without any difficulty but a patient

with asthma has to Exhale the air out

with difficulty due to the

bronchoconstriction therefore fev1 will

be less now sometime it happens that a

patient comes to you and tells you the

doctor I get difficulty breathing

sometime I get chest tightness I

sometimes experience dry cough

difficulty breathing but when you

examine the patient patient at that

point in time is totally normal

why this is because that as I said that

asthma is a reversible disease sometimes

the patient is in a very bad condition

patient is experiencing just tightness

difficulty breathing but after some time

the patient is totally fine all the

tests are normal the examination is

normal there are no findings because it

is a reversible disease so patient has a

normal Baseline Health but sometimes he

experiences bronchoconstriction and

exacerbation of asthma now that patient

is having a total normal examination if

you go for fev1 FEC at that time when

the patient is not having an anasma

attack the patient's fev1 will be normal

the feb1 FEC ratio will also be normal

in that case if you are suspecting that

that patient has asthma then bronchial

provocation tests are done

bronchial provocation tests are the

tests that provoke the

bronchoconstriction

they give certain agents like

methylcholine

that methacholine is given in a

concentration that if it is given to a

normal person normal person would not

experience that much bronchoconstriction

but if it is given to an asthmatic

patient asthmatic patient would cause

severe bronchoconstriction and you will

detect that on spirometry you repeat

spirometry after given giving

methylcholine and you detect a decrease

in fev1 and fvc

but remember that these tests are also

risky if a patient is a severe asthmatic

patient and the spirometry came out to

be normal and you plan to go for

bronchial provocation test sometimes

there is a risk that that patient can

develop status asthmaticus now in real

life these bronchial provocation tests

are not as commonly performed because

sometimes the patient are having severe

asthma and they are coming to you in a

state where they are totally fine they

are totally normal but to diagnose you

give methylcholine and it causes severe

bronchoconstriction anyone state of

systematicus so methylcholine challenges

just for remember them for academic

purposes but in real life these tests

are not commonly performed what you can

do is that you can ask the patient to do

some exercise if the spirometer is

totally normal you can ask the patient

to do some exercise and if there is some

cold air some cold temperature in that

cold air if the patient does some

exercise then there can be slight

bronchoconstriction and you can see a

decrease in the levels of spirometry

so if a patient comes to you with an

estimatic attack you can do spirometry

in that case the spirometry will show

decrease in fev1 to FCC ratio but if the

patient is not experiencing as estimatic

attack at that point when it comes to

you in your clinic

then bronchial provocation tests can be

done which are not commonly performed

and if they were performed then the a

decrease in fev1 by 20 percent is

diagnostic for asthma so in the

diagnosis typical clinical features with

demonstration of reversible

bronchoconstriction on pfts bronchial

provocation test as a second line test

this is how you make the diagnosis of

asthma now there is one another point

that I want to mention here that when

you receive a patient with an asymmetic

attack and you perform spirometry and

the spirometry shows results like this

decrease fev1 to fvc ratio in such case

COPD patients also have the same pattern

on spirometry now how will you

differentiate that whether it is COPD or

it is asthma one important thing in the

clinical history would be that COPD

always have a baseline disease COPD

patients usually have a baseline disease

Baseline obstruction all the time and in

between they get the exacerbations in

asthma patients will say that I was

totally

Leaf of the days but sometimes I so

we're just tightness and difficulty

breathing so that is one important Point

other than that for academic purposes

you can also remember that there is a

bronchodilator reversibility test now if

the patient is having a difficulty

shortness of breath chest tightness you

do you suspect that that patient is

having asthma you perform spirometer you

get results like this then what you can

do is that you can give bronchodilator

challenge you can give bronchodilator to

the patient like albuterol 200 to 400

microgram now when you give Alberta role

to the patient that albuterol will cause

bronchodilation and that bronchodilation

will make it easier for a patient for a

stomatic patient to breathe to Exhale

the air out

so when you perform the spirometry now

after giving the bronchodilator they

will be greater than 12 percent

increased in the forced expired volume

in the first second

but in COPD patient there will not be as

much change there will be no improvement

even after giving bronchodilators

so if you are confused at whether that

patient is having COPD or asthma in that

case you can perform bronchodilator

reversibility test so a patient comes to

you in your clinic with chest tightness

with shortness of breath you suspect

asthma you perform spirometry if the

spirometry it shows decrease ref1 FEC

and you suspect that that patient is

having asthma or COPD you can perform

bronchodilator reversibility now coming

to the classification of s my according

to the National asthma education and

prevention program the classes of asthma

include intermittent asthma persistent

asthma persistent asthma is further

divided into three categories mild

persistent moderate persistent and

severe persistent asthma

now we'll discuss each one of them in

detail the how are they classified on

the basis of their symptoms and their

treatment with each category first

coming to the intermittent asthma a

patient is said to have intermittent

asthma if the patient experiences

symptoms of bronchoconstriction asthma

frequency less than two times a week

waking up because of symptoms at night

less than two times are equal to two

times a month use of short acting beta

Agonist drugs short technique beta

Agonist drugs are the drugs that are

present in the inhalers that cause

bronchodilation less than or equal to

two days per week so you can remember

the word two these classes are basically

categorized based on the symptoms with

which the patient presents so if the

symptoms are slightly Mild they are

classified into intermittent asthma and

when you perform spirometry on these

patients the force expiratory volume is

greater than or equal to 80 percent of

the expected which is a normal value

so these patients are not having that

severe asthma that their fev1 is

deranged but they develop the shortness

of breath they develop difficulty

breathing sometimes

exacerbation requiring steroids less

than one time a year

now how do you treat these patients with

intermittent asthma these intermittent

asthma patients are treated with just

Saba inhaler short acting beta Agonist

inhalers these beta Agonist drugs are

contained in these containers and they

cause bronchodilation drugs like

albuterol are short acting beta agonists

inhaled albuterol 90 microgram per puff

now what you do is that you ask the

patient that whenever you feel chest

tightness whenever you feel shortness of

breath what you do is that you take the

inhaler you shake the inhaler first and

then you exhale the air out then you

hold it around your mouth tightly and

you inhale through your mouth at the

same time press the inhaler

and then you should stop breathing for

at least 10 seconds you should hold the

breath for 10 seconds and after 10

seconds you can exhale through your

mouth

so that there is effective drug

absorption within the lungs two to four

Puffs as needed whenever the patient has

anastomatic attack daily therapy is not

required it is just a rescue inhaler

rescue inhaler means that whenever

patient feels an attack of asthma

whenever patient feels that he is having

shortness of breath at that time patient

will use this inhaler daily therapy is

not recommended in patients with

intermittent asthma they will just have

to use these rescue inhalers only

whenever they feel chest tightness

difficulty in breathing whenever they

feel they are having asthmatic attack

they just use these rescue inhalers

otherwise no drilling inhalers no daily

use drugs are prescribed 2020 Gina

guidelines recommended to add low dose

inhaled corticosterides for daily

therapy now coming to persistent asthma

persistent asthma is further divided

into three categories mild persistent

moderate persistent severe persistent

we'll discuss that how are they

classified then we'll discuss the

treatment of each one of these mild

persistent if the patient is having

symptoms greater than two times a week

waking up at night three to four times

per month with minor limitation of daily

activities

moderate persistent asthma is the one

when the patient is having symptoms of

asthma daily waking up for greater than

one time a week

some limitation of activity of daily

life in severe persistent asthma patient

will be having daily symptoms throughout

the day it's a severe form of asthma

waking up every night because of

difficulty in breathing and there is

Extreme limitation of activity that

patient cannot exercise that patient

cannot perform the daily life activity

because he is I mean getting severe

attack of asthma again and again now

when you perform spirometry on these

patients what you would see is that the

spirometry results will be normal in

mild persistent asthma and feb1 will be

greater than 80 percent whenever the

fev1 is greater than 80 percent of the

predictive value it's normal but when it

is less than 80 it's abnormal in

moderate persistent it's from 60 to 80

percent of the predicted in the severe

persistent it will be even less than 60

percent which is a severe form of asthma

now coming to treatment of each one of

these in the treatment of mild

persistent asthma you give the daily

therapy in intermittent asthma daily

therapy was not recommended only Gina

guidelines recommended that you can add

low dose inhered corticosteroids in mild

persistent asthma daily therapy is

recommended with low dose inhaled

corticosteroids in helicorticosteroids

include productionide fluticasone

other Alternatives that can be used for

daily therapy include leukotriene

receptor antagonist as I said that

leucotrans cause bronchoconstriction so

we antagonize them with leukotriene

receptor antagonists like Montelukast

zaphast these are leukotriene receptor

antagonists and they can be prescribed

to patients as for daily therapy in mild

persistent asthma and whenever the

patient gets attack you ask the patient

to use the short acting beta Agonist

albuterol inhaler as I showed you in the

previous picture so whenever it gets

patient gets the attack patient uses

sub-inl otherwise daily patient is using

inhale corticosteroid inhaler as a daily

therapy now coming to the moderate

persistent asthma and the treatment of

moderate persistent asthma it is a more

severe form of asthma and in which you

have to give daily therapy with inhalers

that contain ludos inhaled

corticosteroid and for metrol for mitral

is basically long acting bit Agonist now

remember one thing that short acting

beta Agonist inhalers can be given alone

but long-acting beta Agonist inhalers

can never be given alone they are given

which steroids combination

so for Mid role is given with a

combination of inhaled corticosteroid

preferably a single inhaler and that

patient uses that single inhaler as a

daily therapy as well as as a rescue

therapy whenever patient gets attack

patient uses that in otherwise patient

also uses that in another daily

now remember as I said that there are

two important components in the

pathogenesis of asthma one is bronchial

inflammation and the other one is

bronchial constriction the inhibit

Agonist inhalers control the

bronchoconstriction they call

bronchodilation

and the steroids they reduce the

inflammation so you we are treating the

both components of asthma other

combinations include inhaled

corticosteroids with long-acting bit

agonists other than format role inhaled

corticosteroids in combination with long

acting muscarinic antagonists inhaled

corticosterides with leukotriene

receptor antagonists and you can add

Saba if you are using the last two

otherwise if you are giving inhaled

corticosteroid with four meter roll

inhaler in a single inhaler you can give

it as a daily therapy as well as a

rescue therapy you did not need to add

Sabah into this

now coming to severe persistent asthma

so we are persistent as much as a severe

form of asthma and in this condition you

need to give inhaled corticosteroids

with long-acting beta Agonist and long

acting muscarinic antagonists inhaled

corticosteroids include buddhistonide

and proticason long-acting beta agonists

include format role and long-acting

muscarinic antagonists muscarinic

antagonists are the drugs that block the

action of parasympathetics some

parasympathetic system causes

bronchoconstriction and if you are

blocking the parasympathetic system

which results in bronchodilation and

they include diode propion bromide

and with this combination you give

rescue inhaler Saba whenever the patient

gets attacked patient uses saba and as a

daily therapy patient uses these drugs

if the patient's asthma is still not

controlled what you need to do is that

you can add oral corticosteroids now we

were avoiding oral corticosteroids

throughout but in severe persistent

asthma which is not controlled with the

inhale drug you need to add oral

corticosteroids because in severe

persistent asthma there is severe

inflammation there is a severe

disability of the patient who cannot

perform the real life activities every

night patient is waking up with an

asymmetic attack you need to add oral

corticosters if it is not controlled

with inhale drugs with that you need to

give inhaled corticosteroids and long

acting beta Agonist

now coming to some general Myers in a

patient who is being treated for asthma

what you need to do is that you need to

do medication review if the patient is

taking beta blockers remember beta

blockers are contraindicated in patients

with asthma if you are ever prescribing

beta blockers to a patient you must ask

any history of asthma if the patient is

having any history of asthma then beta

blockers are contraindicated other than

that NSAIDs as I said that NSAIDs

increase leukotrans and leucotrans cause

bronchoconstriction you ask the patient

to avoid allergen patients really knows

that which thing he is allergic to and

asks them to use impermeable pillow

covers bed sheets treat the comorbs and

if the patient is having good treated

with proton pump inhibitors smoking

cessation is most and highly important

very important for patients with asthma

and you teach the patient use of peak

flow meter this is a picture showing

Peak flow meter in which they exhale the

air and see how much air they are

exhaling out

whenever the patient has an asthma

attack they can exhale out less air and

they can see that by themselves at home

and when they take the inhaler they can

even see the improvement with Peak flow

meter so you teach the patients use of

peak flow meter and I have also made a

video on the treatment of strata

systematic as if a patient gets severe

status asthematicus attack how do you

manage it I have talked about it in

detail in my video on status

systematicus management you can check

out the link in the description below

now in the follow-up when you have

started the therapy you ask the patient

to come back in two or four weeks and

you check the symptom frequency that by

the symptom frequency has decreased or

not you see that whether is the patient

has decreased frequency of developing

excess abations and you do pfts and if

the patient is improving then after some

stable period you can consider step down

therapy now in some patients who are

again and again coming to you and they

are not getting better with the

treatment even with the Step Up therapy

when you are adding more drugs the

patients are not getting better now

whenever you are going for a step up

therapy when you are going to add a drug

remember to see that whether that

patient is compliant with the treatment

or not and also assists the inhaler

technique many patients do not even know

that how to use inhaler and they are

technically wasting drug they are not

even using that inhaler properly teach

them to use inhaler properly and if they

cannot use the inhaler properly ask them

to use spacer this is a picture of

spacer spacer is a device that is

attached with the inhaler and patient

inhales the drug from this part now the

good thing about spacer is that if the

patient misses the drug in one breath

the drug is not wasted the drug is

present in the inhaler and that patient

can in inhale it in second or third

breath now briefly coming to the side

effects of the drugs used in treatment

of asthma inhaled corticosterides the

inhalers that contain corticosteroids

cause oral candidiasis remember as a

patient that whenever they use inhaler

that contain corticosterite they must

rinse their mouth with water

short-acting beta Agonist most commonly

cause slight tremor

oral corticosteroids can cause diabetes

mellitus cataract osteoporosis adrenal

suppression of steroids therefore we

reserve the oral corticosteroids for

very severe asthma if the very end we

give it to the patients an interesting

tidbit in the past grimald cigarettes

were prescribed to the patients with

asthma these grimald cigarettes used to

contain atropine in it atropine is an

anticholinergic which causes

bronchodilation other than that they

used to contain cannabis in it the Tura

in it so they were this is an ad that is

recommending used for of grimald

cigarettes for asthma bronchial trouble

hey fever and laryngitis but now after

all this research we know how much the

tobacco is dangerous for a patient with

asthma smoking cessation is most

important thing for a patient with

asthma the first best intervention that

you can do is in an asthma patient is to

tell them to stop smoking cigarettes

this is just an interesting fact from

the past

in summary we talked about what is

asthma the triggers of asthma the

symptoms the diagnosis with pfts the

classification the intermittent asthma

and the treatment of intermittent asthma

moderate mild persistent moderate

persistence severe persistent asthma and

their treatments the general Meyers the

follow-up causes of inadequate response

side effects of the drugs used for

asthma if you liked my video please

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link of those videos is given in the

description below thank you very much