an informative ppt for medical undergraduates on drugs used in bronchial asthma with jokes and pics..... enjoy reading ..... <3.... satya

1. RESPIRATORY SYSTEM

2. INTERESTING FACTS ABOUT RESPIRATORY
SYSTEM

3. The surface area of the lungs is roughly the same
size as a tennis court.

4. The capillaries in the lungs would extend 1,600
kilometres if placed end to end.

5. A person at rest usually breathes between 12 and
15 times a minute.

6. The breathing rate is faster in children and
women than in men.

9. DRUGS FOR BRONCHIAL
ASTHMA
Dr. V.SATHYANARAYANAN
M.D
PROFESSOR OF

11. BRONCHIAL ASTHMA
 Hyperresponsiveness of tracheo-bronchial
smooth muscle
 resulting in narrowing of bronchial tree
 Wheezing attacks
 polygenic
 Primarily inflammatory condition

16. Mediators in Asthma
 Mediators released are > 100 in number
 histamine, TNFa - immediate
 Prostaglandins, leukotrienes, PAF –
within min
 Interleukins, TNFa – /over hrs

20. Symptoms of Asthma
• Wheezing
• Cough, especially at night
• Chest tightness
• Shortness of breath
• Characteristically occur or worsen at night,
with exercise, with viral infections, or with
exposure to dust, animals, or smoke

25. TYPES
 EXTRINSIC ASTHMA – Commonest,
episodic, allergens involved
 INTRINSIC ASTHMA – without allergens,
Perennial
 EXERCISE INDUCED ASTHMA
 ASTHMA ASSO. WITH COPD

29. APPROACHES TO
TREATMENT
 PREVENTION OF EXPOSURE TO
ALLERGENS
Avoid Grasses, Pollens, Animals
 NEUTRALISATION OF IgE - omalizumab

31. APPROACHES TO
TREATMENT
 REDUCTION OF BRONCHIAL
INFLAMMATION & HYPERREACTIVITY
 Glucocorticoids
 Sodium cromoglicate
 Nedocromil sodium
 Ketotifen
 PAF antagonists

33. APPROACHES TO
TREATMENT
 DILATATION OF NARROWED BRONCHI
 BETA2 receptor agonists
 Methyl xanthines
 Antimuscarinic bronchodilators
 Leukotriene receptor antagonists

35. JOKE WITH ASTHMA
 Matthew sets up Andrew to go on a blind date
with a friend of his.
 But Andrew is a little worried about going out with
someone he has never seen before.
 “What do I do if she’s ugly?” says Andrew, “I’ll
be stuck with her all night.”
 “Don’t worry.” Matthew says. “Just go up to her
door and meet her first. If you like what you see,
then everything goes as planned. If you don’t,
just shout Aaauuuggghhh! and fake an

36. JOKE WITH ASTHMA
 So that night, Andrew knocks at the girl’s door,
and when she comes out he is awe-struck at
how beautiful and sexy she is.
 Andrew’s about to speak when the girl
suddenly shouts, “Aaauuuggghhh!”

37. BETA2 AGONISTS
 Salbutamol (Albuterol )
 Terbutaline
 Bambuterol
 Salmeterol
 Formeterol

38. SALBUTAMOL
 Beta2 stimulation  inc.cyclic AMP
relaxation, decreases mediator release
 Fastest acting , within 5 min, lasts for 2-4 hrs
 Relieves symptoms
 Used to abort acute attacks of asthma
 ADR – tremors, palpitation, restlessness,
ankle edema, hypokalemia
 Orally in severe asthma
 Regular use – downregulation of receptors

45. TERBUTALINE
 Similar to salbutamol
 Used only for symptomatic relief

46. BAMBUTEROL
 Prodrug
 Hydrolysed by pseudocholinesterase into
active drug
 Release over 24 hrs
 Indicated in chronic bronchial asthma
 Single evening dose 10 -20 mg

48. SALMETEROL
 Long acting beta2 agonist
 Slow onset of action
 Used by inhalation
 Twice a day schedule
 For maintenance therapy and nocturnal
asthma

49. FORMOTEROL
 Long acting beta2 agonist
 Acts for 12 hrs when inhaled
 Fast acting as well
 Used as a Regular twice a day schedule for
round the clock bronchodilatation.

51. OTHER BETA AGONISTS
 Adrenaline, ephedrine, isoprenaline
 Less safe – cause cardiac arrhythmias

53. Worried Patient
 Patient: Doctor, when I press my leg it
hurts. Then when I press my chest it hurts,
when I press my head it hurts, and when I
press my stomach it hurts. I'm worried doc,
what's wrong with me?
 Doctor:
Easy straightforward, you have a sore
finger!

54. THEOPHYLLINE
 Xanthine alkaloid
 Good bronchodilator
 Inhibit phosphodiesterase 5, release Ca, block
adenosine receptors
 CNS stimulant,
 increases HR, Diuretic, increases acid
secretion,
 dilate bronchi
 Also used in COPD
 Has low therapeutic index
 Use has declined because of safety

60. THEOPHYLLINE - ADR
 Insomnia, nervousness, flushing
 Tremors
 Vomiting
 Palpitation
 Arrhythmias, seizures in high doses

68. THEOPHYLLINE – DRUG
INTERACTIONS
 Microsomal enzyme inhibitors increases
toxicity
 Enzyme inducers decrease levels
 Theophylline enhances the effects of
furosemide, sympathomimetics,
hypoglycemics
 PK – elimination changes 1st order to 0 order
 Has low therapeutic index – need monitoring

70. USES
 Bronchial asthma
 COPD
 Apnoea in premature infant

72. ANTIMUSCARINIC
BRONCHODILATORS
 Ipratropium bromide, oxitropium, tiotropium
 Block M3 receptors
 Inhaled  less systemic effects
 Slower response
 Better suited for regular prophylactic use
 Less effective than salbutamol
 Useful in COPD, refractory asthma

76. The Specialist
 'What kind of work do you do?' a woman
passenger enquired of the man travelling in
her train compartment.
 'I'm a Naval surgeon,' he replies.
 'My word!' spluttered the woman, 'How you
doctors specialise these days.'

77. CORTICOSTEROIDS
 Suppress inflammatory response
 Do not dilate bronchi
 Afford complete & sustained relief
 Decrease disease progression
 Inhaled steroids – only few ADR
 Long term systemic therapy – more ADR

78. CORTICOSTEROIDS
 Prednisolone – given orally
 Beclomethasone
 Fluticasone
 Budesonide all given by inhalation
to minimise systemic side effects

80. Effects of Inhaled Corticosteroids on
Inflammation
Compromis
Compromis
ed
ed
Epithelium
Epithelium Intact
Intact
Thickened BM Epithelium
Epithelium
Thickened BM
Inflammatory Cells
Inflammatory Cells ↓
↓
Inflammatory
Inflammatory
Cells
Cells
Laitinen et al. J Allergy Clin Immunol 1992;90:32-

81. INHALED STEROIDS
 High topical activity
 ‘ Step 1’ for all patients
 Indicated if beta2 agonist required daily
 ADR – hoarseness of voice, dysphonia,
oropharyngeal candidiasis, sore throat
 Safe during pregnancy
 > 600 micrograms/day  systemic effects
 C/I - Infection

88. MAST CELL STABILIZERS
 Sodium cromoglycate, nedocromil
 Alternative to inhaled steroids
 Inhibit degranulation of mast cells – prevent
release of mediators
 Given by inhalation
 Prevent bronchospasm induced by allergens,
irritants, cold air, exercise
 Other Uses – allergic rhinitis, conjunctivitis
 ADR- mild, like cough, throat irritation

96. KETOTIFEN
 H1Antihistamine
 Like cromoglycate
 Orally given
 ADR – Sedation, dry mouth, weight gain
 1-2 mg BD
 Also used in other allergic disorders

101. LEUKOTRIENE RECEPTOR
ANTAGONISTS
 Montelucast, zafirlucast
 Similar efficacy like low dose steroids
 Used in prophylaxis alternate to steroids
 More acceptable in children
 Effective in aspirin induced asthma
 Very safe, few side effects- headache, rash
 rarely cause churg- strauss syndrome
 2nd – 3rd line role

102. 5-LO
inhibitors
- zileuton
Cysteinyl-
LT receptor
antagonists
-
zafirlukast
-

107. ZILUTON
 5 Lipoxygenase inhibitor
 Prevent all LT induced responses
 Efficacy similar to LT antagonists
 Limitations – short duration, hepatotoxicity

110. OMALIZUMAB
 A monoclonal antbody against IgE
 Binds to IgE  form a complex make IgE
not bind to IgE receptors on mast cells and
basophils  inhibition of allergic response
 Given S.C once in 2-4 weeks
 ADR – Well tolerated, pain at the site of inj.,
allergy
 Caution – a very small% developed cancers
 Uses – prophylaxis in patients with moderate to
severe asthma >12 years

112. STATUS ASTHMATICUS
 Also known as refractory asthma , acute
severe asthma
 May be life threatening
 A medical emergency
 URI is mostly the precipitant
 Other triggers – drugs, stress, allergens,
abrupt withdrawal of steroids after prolonged
use

113. A JOKE ON SAVING LIFE
 In a school in Poland the teacher asks, "Has
any of you ever saved somebody's life?“
 A little boy raises his arm, "Yes, my little
nephew's.“
 "How did it happen? Tell us!" asks the teacher.
 The little Polack says, "I hid my sister's birth
control pills!"

115. STATUS ASTHMATICUS
 Nebulized salbutamol (2.5-5 mg )+ ipratropium
(0.5 mg ) intermittent inhalation
 Intermittent high flow humidified Oxygen
inhalation
 Hydrocortisone hemisuccinate 100 mg i.v stat
followed by 100 – 200 mg 4-8 hourly infusion
 Salbutamol/Terbutaline 0.4 mg i.m/s.c may be
added
 Antibiotics
 i.v fluids + sodium bicarbonate infusion
 Intubation and mechanical ventilation, if needed
 NO SEDATION

119. Can I call you Little Asthma?
'Cause you take my breath
away……
Tweet Share

120. CHOICE OF TREATMENT – MILD
EPISODIC ASTHMA
 Symptoms < once daily, normal between
attacks
 Inhaled beta2 agonist at onset of episode –
step1
 Regular Prophylaxis not required

122. SEASONAL ASTHMA
 inhaled cromoglycate or low dose
inhal.steroids
 Regularly 3-4 weeks before and after season
 Individual episodes – short acting inhal. Beta2
agonist

124. MILD CHRONIC ASTHMA
WITH OCCASIONAL
EXACERBATIONS
 Symptoms once daily
 Regular Low dose inhal. Steroids or
cromoglicate – step2
 Episode treatment with short acting inhal.
Beta2 agonist

126. MODERATE ASTHMA with
frequent exacerbations
 Attacks affect activity
 Occur > 1/day
 Increasing doses of Inhal. Steroids upto 800
micrograms/day + inhal. Long acting beta2
agonist – step3
 Or LT antagonist for steroids
 Theophylline may be used

128. SEVERE ASTHMA
 Continuous symptoms, activity limitation,
frequent attacks requiring hospitalisation
 Regular high dose inhaled steroids ( 800 –
2000 micrograms/ day ) with spacer +
 Inhaled salmeterol BD
 Leukotriene antagonist/ Oral theophylline S.R/
oral beta2 agonist/ inhaled ipratropium – step4
 Not controlled  oral steroids – step5

129. WARNINGS
 BETA BLOCKERS even topical or selective
may precipitate asthma
 Can be fatal  so contraindicated
 Overuse of beta2 agonists  can cause
asthma related deaths

132. NAEPP Guidelines
Classification of Asthma Severity
4 Severe Persistent
3 Moderate Persistent
2 Mild Persistent
1 Mild Intermittent

133. Asthma Treatment
Summary
Mild Intermittent
Use: salbutamol, Asthma Action Plan
Mild Persistent
Use: salbutamol and Controller medications (low dose
steroids, nedocromil, cromolyn, montelukast)
Moderate Persistent
Use: Combination of medications (low to medium dose
steroid plus long acting beta agonist, and/or Leukotriene
modifiers)
Severe Persistent
Use: High dose inhaled steroids, long acting beta
agonist, and leukotriene modifier. May need oral
steroids

135. PADDY IN THE CONFESSION
BOX
 Paddy NcNaughty went to confession : "Bless
me, Father, for I have sinned.“
 Priest asked "And what is it that you have done,
my son?"
 "I made love to one of the girls in the village.“
 "My God!" said the priest, "and which of the
village girls did you commit sin with?"

"Ah, Father, that I cannot tell."


137. PADDY IN THE CONFESSION
BOX
 "And if you will not tell me, then I shall not
forgive your sins "
 "Ah dear!" said Paddy.
 "Was it Molly O'Flaherty?" asked the priest.
 "No, it was not Molly O'Flaherty."
 "Then was it Flora Fitzgibbons?"
 "Ah no," said Paddy, "it was not Flora
Fitzgibbons."

138. PADDY IN THE CONFESSION
BOX
 Was it Maggie Muldoon, then?" persisted
the priest.
 "Ah, sure no, it was not Maggie Muldoon."
 "Then who in heaven's name was it?"
 "Ah, sure, Father -- that I cannot tell.“
 "And if you don't tell me I shall not give
you absolution."


139. PADDY IN THE CONFESSION
BOX
 "Ah, Father, that's too bad!" said Paddy
and walked out of the confessional.
 His friend, Michael, was waiting outside.
He asked "Well, Paddy, did you get your
sins forgiven?"
 "No," said Paddy, "but I got the names
of few great girls to fun with "

143. LAUGHTER BOOSTS IMMUNE
SYSTEM
 Young children laugh an average of 300 times a
day, while adults average somewhere between
15 to 100 times.
 The saying that ‘Laughter is the best medicine’
may have some truth to it. Laughing helps to
boost the immune system.


146. THANK U…