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Asthma

Asthma (BA) is a heterogeneous disease characterized by chronic inflammation of the airways, the presence of respiratory symptoms such as wheezing, shortness of breath, chest congestion, and cough that vary in time and intensity and present with variable airway obstruction.

Status asthmaticus is defined as an episode of acute respiratory failure (ARF) during an exacerbation of asthma (equivalent to "life-threatening asthma" and "near-fatal asthma")

Pathogenesis​

  1. Eosinophilic inflammatory bronchoconstriction: antigen - inflammation - cytokines (prostaglandins, leukotrienes, etc.) - bronchoconstriction

  2. Remodeling of the airways: inflammation - dysplasia/hyperplasia of the airway epithelium, collagen deposition, excess secretion

Classification​

By severity​

  1. Before therapy:
    • I: intermittent - daytime symptoms less than 1 time per week; nocturnal symptoms <2 times a month, FEV1 or PEF ≥80% predicted, daily PEF lability <20%
    • II: persistent mild - symptoms more than 1 time per week, but less than 1 time per day, FEV1 or PEF ≥ 80%, daily PEF lability 20%-30%
    • III: persistent moderate - daily symptoms; exacerbations disturb physical activity and sleep, FEV1 or PEF - 60-80%, variation in PEF > 30%
    • IV: severe persistent - persistent symptoms, limited physical activity, FEV1 or PEF <60%, PEF daily lability > 30%
  2. During therapy:
    • Light BA
    • Moderate BA
    • Severe BA
    • Uncontrolled

Phenotypes​

  1. Allergic asthma: the most common and easily recognizable phenotype that usually begins in childhood
  2. Non-allergic asthma: more common and onset in adults, not associated with allergies
  3. Aspirin BA: isolated into a separate phenotype, in the presence of hypersensitivity to acetylsalicylic acid and other non-steroidal anti-inflammatory drugs
  4. Late Onset Asthma: Some patients, especially women, develop asthma for the first time in adulthood (over 40 years of age)
  5. Asthma with fixed airway obstruction: some patients with a long history of asthma due to remodeling of the bronchial wall
  6. BA in obese patients

Etiology​

Factors

  • Intrinsic: genetics, obesity, gender
  • External: allergens, infectious agents, prof. factors, environmental pollution

Trigger: sensitized inhaled antigen

Diagnostics​

Characteristic respiratory symptoms of asthma:

  • wheezing, shortness of breath, cough, chest tightness, especially more than one symptom;
  • symptoms are often worse at night or early in the morning;
  • symptoms change over time and in intensity; Symptoms are caused by viral infections (colds), exercise, exposure to allergens, weather changes, laughter, or irritants such as car exhaust, smoke or strong odors.

Laboratory research

  • Complete blood count: increase in the number of eosinophils
  • General sputum analysis: increased number of eosinophils (not always), Kurshman's spirals (interlacing of small bronchi), Charcot-Leiden crystals (necrotic neutrophils that previously infiltrated the bronchus wall)
  • Allergy diagnostics: elevated level of total IgE
  • Eosinophilic cationic protein (ECP)

Instrumental​

  1. Spirometry: positive bronchodilator test - increase in FEV1≥12% and at the same time the absolute increase is 200 ml or more after inhalation of 200-400 μg of salbutamol.
  2. Peakflowmetry - determination of peak expiratory flow rate (PEF): Increase in PEF after inhalation of a bronchodilator by 60 l / min (or by a value of ≥20% PEF measured before inhalation of a bronchodilator) or a change in PEF during the day by more than 10 % indicate the presence of BA
  3. Monitoring PEF (peak flowmeter)

Wording​

The diagnosis should include:

  • etiology (if established);
  • degree of severity
  • level of control;
  • comorbidities that may affect the course of asthma;
  • if present, an exacerbation with an indication of its severity.
Examples
- Allergic bronchial asthma, moderate controlled course. Perennial allergic rhinitis, mild course. Sensitization to house dust mites allergens.
- Non-allergic bronchial asthma, moderate, insufficiently controlled course. Recurrent polyposis sinusitis. Intolerance to NSAIDs ("aspirin triad").
- Allergic bronchial asthma, moderate, insufficiently controlled course. Moderate exacerbation. Seasonal allergic rhinitis, severe. Sensitization to pollen allergens (trees).
- Non-allergic bronchial asthma, moderate uncontrolled course, severe exacerbation. Asthmatic status, compensated stage. Obesity II Art.

Dif diagnosis​

  • COPD
  • URT lesions
  • Gastroesophageal reflux
  • Allergic bronchopulmonary aspergillosis
  • Bronchiectasis
  • Interstitial lung lesions (fibrosing diseases, lung lesions in rheumatological pathologies, etc.)
  • Pulmonary tuberculosis
  • Lung tumors
  • Side effects of drugs (ACE inhibitors, beta-blockers, etc.)

Treatment​

  1. achieving and maintaining control
  2. relief of airway inflammation
  3. prevention of exacerbations and future risks

Non-drug​

  1. Education of patients and their families
  2. Avoid contact with the causative allergen, incl. tobacco smoke
  3. Exercises, massages, non-traditional. the medicine
  4. Hypoallergenic diet

Medication​

It is recommended to use a stepwise approach in choosing the amount of therapy. At each stage of therapy, patients can use emergency drugs (short and long-acting bronchodilators (formoterol only).

Stage 1 (intermittent asthma): short-acting inhaled ß2-agonists (salbutamol, fenoterol) as needed. Low-dose ICS may be prescribed (budesonide 200–400 mcg/day, fluticasone 100–250 mcg/day, ciclesonide 80–160 mcg/day, beclomethasone 200–500 mcg/day)

Stage 2 (usually mild persistent asthma). Regular intake of one of the maintenance drugs is needed, usually low-dose ICS (see step 1), and SABA if needed. The antileukotriene drugs (ALR) (montelukast) are an alternative. IGCS are more effective than LRA.

Stage 3 (usually corresponds to moderate persistent asthma). It is recommended to prescribe combined ICS / LABA in low-medium doses (doses are calculated according to ICS, see step 2; the maximum dosage of LABA is 54 mcg per day for formoterol, 100 mcg for salmeterol, 22 mcg for vilanterol). The use of SABA is recommended if necessary. Formoterol/budesonide (4.5/80-160) may be used as a "single inhaler" regimen for daily monitoring therapy for acute symptoms.

An alternative to combination drugs at this stage may be:

  • a) mono ICS in medium or high doses (budesonide 400-2000 mcg/day, fluticasone 250-1000 mcg/day, ciclesonide 160-640 mcg/day, beclomethasone 500-2000 mcg/day); or
  • b) low-dose mono ICS plus LRA (or sustained release theophylline).

Stage 4 (usually corresponds to severe persistent asthma). Combination ICS/LABA at medium/high doses is recommended (see step 3). For patients with a history of asthma exacerbations, the addition of tiotropium in the form of a soft mist inhaler (mist soft inhaler) is recommended. SABA inhalation as needed or formoterol/budesonide combination in single inhaler mode.

An alternative to combined drugs at this stage may be the appointment of mono-IGCS in medium / high doses plus LRA (or theophylline extended release).

Stage 5 (severe, uncontrolled asthma on stage 4, but with persistent daily symptoms and frequent exacerbations). The addition of additional drugs is required - tiotropium in the form of a soft mist inhaler (mist soft inhaler) and / or oral corticosteroids in the minimum effective dosages (the patient should be informed about the risk of developing undesirable effects).

Other​

  • Allergen-specific immunotherapy (ASIT)
  • Treatment of allergic rhinitis in asthma
  • Vaccination - to reduce risk
  • Vitamin D use: vitamin D deficiency can lead to impaired lung function, increased exacerbations and reduced effect of ICS

At the hospital (+ to the above)​

  • Oxygen therapy, heliox (a mixture of helium and oxygen with a helium content of 60 to 80%)
  • Improving the drainage function and sanitation of the bronchial tree - massage, vibroacoustic effects, exercises
  • Non-invasive ventilation of the lungs (in severe cases)
  • VL. Absolute indications for respiratory support of mechanical ventilation:
    • stopped breathing;
    • change of consciousness (stupor, coma);
    • unstable hemodynamics (SBP<70 mmHg, heart rate<50/min or >160/min);
    • general fatigue, exhaustion of the patient;
    • fatigue of the respiratory muscles;
    • refractory hypoxemia (PaO2 <60 mmHg, with FiO2 >60).
  • Intravenous aminophylline and theophylline (should not be used in the treatment of asthma exacerbations due to their low efficacy and safety profile, and the greater efficacy and relative safety of SABA)

Complications​

  • Asthmatic status
  • Respiratory failure
  • Lung diseases (Spontaneous pneumothorax, Atelectasis, Emphysema, Pneumosclerosis, Hyperinflation of the lungs, etc.)
  • Pulmonary heart

Prognosis​

In general, the disease is chronic and slowly progressive, adequate treatment can completely eliminate the symptoms, but does not affect the cause of their occurrence. The prognosis for life and work capacity with adequate therapy is conditionally favorable. Remission periods can last for several years

Asthma Control Test (ACT)

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