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ALAS PERUANAS UNIVERSITY

FACULTY OF HUMAN MEDICINE AND HEALTH SIENCES

ASTHMA

SUBJECT

: ENGLISH II

TERM

: 2016 III

PROFFESOR

: LIC.JANETH LOPEZ MEJIA

STUDENT

: ROSARIO SUSSEL ESCRIBAS VALERO

CYCLE

: III

ROOM

: 302

YEAR

: 2016

pg. 1

INDEX
Dedication .............................................................................................................. 3
INTRODUCTION:.......................................................................................................... 5
Chapter I: Framework:.................................................................................................6
1.

DEFINITION:.......................................................................................................6

1.1.

What is Asthma?............................................................................................6

1.2.

What causes asthma?...................................................................................6

1.3.

SYMPTOMS....................................................................................................6

1.4.

DIAGNOSIS:...................................................................................................7

1.5. ESTABLISH DIAGNOSIS OF ASTHMA AND DETERMINE LEVEL OF


SEVERITY:................................................................................................................. 7
2.

MEDICAL HISTORY...............................................................................................8

3.

PATHOPHYSIOLOGY............................................................................................8

4.

PHARMACOTHERAPY:.........................................................................................9

5.

TREATMENT........................................................................................................10

6.

The Peru Urban versus Rural Asthma (PURA) Study:.....................................11


6.1.

Study sites....................................................................................................11

6.2.

Spirometry....................................................................................................12

6.3.

Allergy skin testing......................................................................................12

6.4.

Prevalence of asthma..................................................................................12

Chapter II: Conclusions.............................................................................................13


Chapter III: Bibliographyc References:....................................................................14

pg. 2

Dedication

[Capte la atencin de los lectores


mediante una cita importante
extrada del documento o utilice
este espacio para resaltar un punto
clave. Para colocar el cuadro de
texto en cualquier lugar de la
pgina, solo tiene que arrastrarlo.]

pg. 3

INDEX
Dedication ................................................................................3
INTRODUCTION:...........................................................................5
Chapter I: Framework:.......................................................................6
1.

DEFINITION:...........................................................................6

1.1.

What is Asthma?...................................................................6

1.2.

What causes asthma?.............................................................6

1.3.

SYMPTOMS.........................................................................6

1.4.

DIAGNOSIS:.........................................................................7

1.5. ESTABLISH DIAGNOSIS OF ASTHMA AND DETERMINE LEVEL OF


SEVERITY:...................................................................................7
2.

MEDICAL HISTORY.....................................................................8

3.

PATHOPHYSIOLOGY...................................................................8

4.

PHARMACOTHERAPY:.................................................................9

5.

TREATMENT............................................................................10

6.

The Peru Urban versus Rural Asthma (PURA) Study:...........................11


6.1.

Study sites.........................................................................11

6.2.

Spirometry.........................................................................12

6.3.

Allergy skin testing..............................................................12

6.4.

Prevalence of asthma..................................................................................12

Chapter II: Conclusions.............................................................................................13


Chapter III: Bibliographyc References:....................................................................14

pg. 4

INTRODUCTION:
Although asthma is often believed to be a disorder localized to the lungs,
current evidence indicates that it may represent a component of systemic
airway disease involving the entire respiratory tract, and this is supported by the
fact that asthma frequently coexists with other atopic disorders, particularly
allergic rhinitis.
It is more prevalent in children with a family history of atopy, and symptoms and
exacerbations are frequently provoked by a wide range of triggers including viral
infections, indoor and outdoor allergens, exercise, tobacco smoke and poor air
quality. Many infants and preschool children experience recurrent episodes of
bronchial symptoms, especially wheezing and cough, beginning at a few
months of age, mainly during a lower respiratory tract infection, and since a
clinical diagnosis of asthma usually can be made with certainty by age 5, the
early diagnosis, monitoring and treatment of respiratory symptoms are
essential. Even though children have a higher overall prevalence of asthma
compared to adults.
As poorer countries undergo rapid urbanisation and development, rates of
asthma have increased. These increases have been reported across
continents.1 It has become clear that asthma is no longer a developed country
disease. Worldwide, it is reported that the prevalence of asthma is
approximately 300 million.

pg. 5

Chapter I: Framework:
1. DEFINITION:
1.1. What is Asthma?
Asthma is an inflammatory disorder
of

the

respiratory

system,

particularly of the bronchioles, the


major passages for air into the
lungs.

During

an

attack,

the

bronchioles become constricted and


the volume of oxygen reaching the
alveoli

is greatly reduced. The

patient feels short of breath and


anxious. An asthmatic patient often
suffers from hay fever, allergic dermatitis, and wheezing, but attacks of asthma
are more severe.
1.2. What causes asthma?
Correlates very closely with a number of variables from weather and air quality
to presence of allergens to heavy exercise, smoking, stress, and certain
environmental pollutants. Heredity is clearly an influence as well; patients with a
family history of asthma and atopy are at significantly higher risk of developing
asthma.
1.3. SYMPTOMS
Symptoms suggestive of asthma include episodic wheezing and cough with
nocturnal, seasonal or exertional characteristics. Infants and children with
frequent episodes of "bronchitis" are likely to have asthma. Atopic and positive
family histories for asthma, particularly when associated with symptoms, should
encourage one to consider a diagnosis of asthma. Eliciting symptoms should
emphasize characterizing the current classification scheme that describes
frequency per week, changes in physical activity, diurnal variation, and seasonal
variation. It is important to recognize that patients with asthma are
heterogeneous, falling into every age group, from infancy to older age, and
presenting a spectrum of signs and symptoms that vary in degree and severity
from patient to patient, as well as within an individual patient over time.
pg. 6

Symptoms
Wheezing
Breathlessness
Cough, productive or dry
Chest discomfort
Pattern of symptoms
Perennial/seasonal
Episodic/continual
Diurnal
Severity of symptom classification
Number of symptom episodes per week
Number of nocturnal symptoms per month

Objective measures of lung function (forced expiratory volume in one


second [FEV1], peak expiratory flow rate [PEFR], PEF variability)

1.4. DIAGNOSIS:
The diagnosis of asthma involves a thorough medical history, physical
examination, and objective assessments of lung function (spirometry preferred).
Bronchoprovocation challenge testing and assessing for markers of airway
inflammation may also be helpful for diagnosing the disease, particularly when
objective measurements of lung function are normal despite the presence of
asthma symptoms.
1.5. ESTABLISH DIAGNOSIS OF ASTHMA AND DETERMINE LEVEL OF
SEVERITY:
Recommendations:
The diagnosis of asthma is based on the patient's medical history,
physical examination, pulmonary function tests and laboratory test
results.
Spirometry is recommended for the diagnosis of asthma.
The level of asthma severity is determined by both impairment and
risk.
Asthma triggers
Viral respiratory infections
Environmental allergens
pg. 7

Exercise, temperature, humidity


Occupational and recreational allergens or irritants
Environmental irritants (perfume, tobacco smoke, wood-burning
stoves)
Drugs (aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], betablocker) and food (sulfites).
Other historical components
Emergency department visits and hospitalization
Medication use (especially oral steroids)
Lung function, PEFR variability
Associated comorbidities, e.g., rhinitis, sinusitis, gastroesophageal
reflux (GERD)
Clinical testing
Accurate spirometry is recommended in every patient five years of age
or older at the time of diagnosis.
Additional studies done, tailored to the specific patient.
- Allergy testing (e.g., skin testing, blood testing, in vitro-specific IgE
antibody testing)
- Chest radiography, to exclude alternative diagnosis
- Bronchial provocation testing if spirometry is normal or near normal)
2. MEDICAL HISTORY
The diagnosis of asthma should be suspected in patients with recurrent cough,
wheeze, chest tightness and shortness of breath. Symptoms that are variable,
occur upon exposure to allergens or irritants that worsen at night and that
respond to appropriate asthma therapy are strongly suggestive of asthma.
Alternative causes of suspected asthma symptoms should be excluded, such as
chronic obstructive pulmonary disease (COPD), bronchitis, chronic sinusitis,
gastroesophageal reflux disease, recurrent respiratory infections, and heart
disease.
3. PATHOPHYSIOLOGY
Asthma symptoms most commonly occur in the setting of chronic and often
systemic inflammation, which is probably present even when there is no
evidence of clinical symptoms. Asthma is also characterized by considerable
variability in activity since symptoms and exacerbations can be triggered by a
pg. 8

number of different factors. In addition, repeated exacerbations may help


perpetuate the disease. The relative contribution of each trigger to disease
activity may change with the age of the child. Asthma is particularly complex in
children because several elements of the immune system including antigen
presentation, T-cell function and antibody production are immature and thus
facilitate atopic responses Interactions between the rate of immune system
maturation and lung growth and development during the first years of life seem
to be crucial in the development of asthma In addition, the airways of infants
and children are more susceptible to obstruction due to their smaller size and
the soft ribcage offers poor support for the underlying lung, which recoils to
volumes more likely to cause airway closure. All of these phenomena are
influenced by the childs genes and by the interaction between genetic,
developmental and environmental factors.
Bronchial inflammation: Bronchial inflammation is a central characteristic of
most patients who have asthma symptoms, and involves changes at the
epithelial level, recruitment of inflammatory cells, and production of multiple
mediators. It is closely associated with airway hyperresponsiveness. Cellularity
and other characteristics of inflammation depend upon trigger and age and may
differ between asthma phenotypes. Inflammation may persist to a varying extent
during the intervals between exacerbations.
Nasal inflammation: In adult asthma, nasal inflammation is found even in the
absence of symptoms and nasal allergen challenge results in increased
bronchial inflammation and vice versa (105107). Although this has not yet
been shown in children, it appears to correlate with the clinical histories of many
children with allergic asthma.
4. PHARMACOTHERAPY:
The goal of pharmacotherapy is control of symptoms and prevention of
exacerbations with a minimum of drugrelated side-effects. Treatment should be
given in a stepwise approach according to the persistence, severity, and/or
frequency of symptoms and should take into account the presenting asthma
phenotype. It should be noted that some children will not respond to specific
therapies. Children starting a new therapy should be monitored and changes
made where appropriate. Medications currently available for childhood asthma
include:
Reliever medications
pg. 9

Short-acting inhaled b2 agonists


Other bronchodilators Controller medications
ICS
LTRA

Long-acting b2 receptor agonists (LABAs) (only in combination with ICS)


Sustained-release theophylline
Anti-IgE antibodies
Cromolyn sodium
Oral steroids

5. TREATMENT
The primary goal of asthma management is to achieve and maintain control of
the disease in order to prevent exacerbations (abrupt and/or progressive
worsening of asthma symptoms that often require immediate medical attention
and/or the use of oral steroid therapy) and reduce the risk of morbidity and
mortality. The level of asthma control should be assessed at each visit, and
treatment should be tailored to achieve control. In most asthma patients, control
can be achieved through the use of both avoidance measures and
pharmacological interventions. The pharmacologic agents commonly used for
the treatment of asthma can be classified as controllers (medications taken
daily on a long-term basis that achieve control primarily through antiinflammatory effects) and relievers (medications used on an as-needed basis
for quick relief of bronchoconstriction and symptoms). Controller medications
include ICSs, leukotriene receptor antagonists (LTRAs), long-acting beta2agonists (LABAs) in combination with an ICS, and anti-IgE therapy. Reliever
medications include rapid-acting inhaled beta2-agonists and inhaled
anticholinergics. Allergen-specific immunotherapy may also be considered in
most patients with allergic asthma, but must be prescribed by physicians who
are adequately trained in the treatment of allergies. Systemic corticosteroid
therapy may also be required for the management of acute asthma
exacerbations. When asthma control has been achieved, ongoing monitoring is
essential to establish the minimum maintenance doses required to maintain
control. However, because asthma is a variable disease, treatment may need to
be adjusted periodically in response to loss of control. It is also imperative that
all asthma patients be empowered to take an active role in the management of
their disease. This can be accomplished by providing patients with a
personalized written action plan for disease management and by educating the
patient about the nature of the disease, the role of medications, the importance
of adhering to controller therapy, and the appropriate use of inhaler devices
Usual initial treatment is with short-acting beta2 -agonist (albuterol)
administered by nebulizer or MDI/spacer. Nebulized albuterol (2.5 mg/3 mL);
depending on response to therapy, this dose may be repeated at 20-munite
intervals for up to three times. Albuterol MDI/spacer 2-6 puffs; depending on
response to therapy, this dose may be repeated at 20-minute intervals for up to
three times. Alternatives: Levalbuterol Nebulized levalbuterol (1.25mg/3mL);
depending on response to therapy, this dose may be repeated three times at 20

pg. 10

minute intervals. Levalbuterol MDI/spacer 2-6 puffs; depending on response to


therapy, this dose may be repeated three times at 20 minute intervals.
Dose for those over 12 years of age is 0.63 mg (via nebulizer) three
times daily (every six to eight hours). If patient does not exhibit adequate
response, may increase dose to 1.25 mg via nebulizer three times daily
(every six to eight hours).
Dose for children 6-11 years of age is 0.31 mg (via nebulizer) three times
daily. Routine dosing should not exceed 0.63 mg three times daily.
Ipratropium added to nebulized beta2 -agonist (albuterol)
Nebulized dose for adults and those over 12 years of age is 0.5 mg every
four hours.
Strongly consider systemic corticosteroids in patients with acute asthma
exacerbation. Corticosteroids aid symptom resolution and prevent
asthma relapse.
Recommendations
Careful evaluation and recognition of asthma triggers is important in
patient education, environmental control and prognosis.
Identification of asthma phenotype should be always attempted,
including evaluation of atopic status.
Asthma symptoms between exacerbations (interval symptoms) are a
major factor in phenotyping childhood asthma.
In infants particularly, a confident diagnosis of asthma is difficult to make.
In preschool and school-age children with recurrent viral exacerbations,
the term virus-induced asthma is preferable to terms that include
wheeze.
6. The Peru Urban versus Rural Asthma (PURA) Study:
6.1. Study sites
We show the location and altitude of both regions in figure 2. Lima, the highly
urbanised capital city of Peru, is located on the central coast and has a
population of approximately 10 million. The site for our study in Lima was
Pampas de San Juan de Miraflores, a peri-urban shanty-town located 25 km
south of central Lima. This community is described in detail elsewhere.26 27 the
population mostly comprises highland immigrants. Homes are made mostly of
concrete or plywood, clustered tightly with paved and unpaved roads separating
each city block. A four-lane highway divides the community in half. Average
ambient temperature in Lima ranges between 17C and 30C year-round, and
relative humidity (RH) ranges between 55% and 80%. Annual precipitation in
Lima is 50mm per year.

pg. 11

6.2. Spirometry
We performed spirometry with a
portable, battery-operated, handheld
spirometer (SpiroPro, Jaeger/Cardinal
Health,
Hoechberg,
Germany).
SpiroPro uses disposable, single-use
factory-calibrated pneumotachometer
tubes (pneumotachs). We asked
participants to withhold any shortacting bronchodilators within 8h and
long-acting bronchodilators for 24
48h of testing unless clinically
necessary; however, we did not have
instances where this occurred. Our
criteria were based on those
European
Respi/European
Respiratory
Society
American
Thoracic Society and European Respiratory
Society
(ATS/ERS) which specify 4h for short-acting bronchodilators and 12 h for longacting bronchodilators. We revisited participants who reported having a
respiratory infection in the last 2 weeks on a later date. Participants with heart
rate >140, systolic blood pressure >185 or diastolic blood pressure >105 would
not have been eligible for testing on that day, although this did not occur. We
obtained information on smoking, alcohol and caffeine consumption in the
immediate period before testing, although these were not considered exclusion
criteria.

6.3. Allergy skin testing


We placed 1244 skin allergy tests (Lima=614, Tumbes=630). In Lima, 96.9% of
positive control tests resulted in positive reactions, while 85.8% of negative
controls resulted in negative reactions. In Tumbes, a similar 95.1% of positive
control tests were interpreted as positive, while 98.7% of negative controls
showed up as negative. This disparity between negative control testing in Lima
and Tumbes may reflect increased baseline skin irritability in Lima, given higher
observed rates of atopy in Lima.

pg. 12

6.4. Prevalence of asthma


We found current asthma prevalence to be 12% (84/725) in Lima and 3%
(22/716) in Tumbes. Current asthma was defined as wheeze symptoms and/or
use of asthma medication in the past 12months. In Lima, 52% (44/84) of
patients with asthma presented with mild intermittent asthma, and in Tumbes,
55% (12/22) of patients with asthma were classified as mild intermittent. Only
5% (4/84) of patients with asthma in Lima presented with severe persistent
symptoms compared with 14% (3/22) in Tumbes.

Chapter II: Conclusions


A diagnosis of asthma should be suspected in patients with recurrent cough,
wheeze, chest tightness and dyspnea, and should be confirmed using objective
measures of lung function (spirometry preferred). Allergy testing is also
recommended to identify possible triggers of asthma symptoms.
In most patients, asthma control can be achieved through the use of avoidance
measures and appropriate pharmacological interventions. ICSs represent the
standard of care for the majority of asthma patients. For those who fail to
achieve control with low-to-moderate ICS doses, combination therapy with a
LABA and ICS is the preferred treatment choice in most adults. LTRAs can also
be used as add-on therapy if asthma is uncontrolled despite the use of low-tomoderate dose ICS therapy, particularly in patients with concurrent allergic
rhinitis. Anti-IgE therapy may be useful in select cases of difficult to control
asthma. Allergen-specific immunotherapy is a potentially disease-modifying
therapy, but should only be prescribed by physicians with appropriate training in
allergy. All patients with asthma should have regular follow-up visits during
which criteria for asthma control, adherence to therapy and proper inhaler
technique should be reviewed.

pg. 13

Chapter III: Bibliographyc References:


Archives:

Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns


K, Malkiewicz J, Manney S, Moyer L, Myers C, Myers N, OBrien M,
Rethwill M, Schaefer K, Uden D. Institute for Clinical Systems
Improvement. Diagnoais and Management of Asthma. Updated July
2012.87:9-18. Available from:
https://www.icsi.org/_asset/rsjvnd/Asthma.pdf

Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns


K, Malkiewicz J, Manney S, Moyer L, Myers C, Myers N, OBrien M,
Rethwill M, Schaefer K, Uden D. Diagnosis and treatment of asthma
in childhood: a PRACTALL consensus report: Institute for Clinical
Systems Improvement (ICSI); 2012 Jul. 30: 6-16. Abailable from:
http://www.eaaci.org/attachments/878_PRACTALL%20Consensus
%20Report%20PP.pdf

Videos:

Dr. Artour Rakhimov, New 3D Asthma Medical Animation (Causes


and Treatment) 2015 September 15 [cited 2016 May 7] [4:03 min]
Available from: https://www.youtube.com/watch?v=EsjnGYoi6_4

Dr. Joel Wallach, Asthma Patients 2015 December 9 [cited 2016


May 14] Available from: https://www.youtube.com/watch?v=Je3ad9g34U

BupaHealth, How an asthma attack occurs, 2013 July 3 [cited 2016


May 15] [2:01 min] Available from: https://www.youtube.com/watch?
v=Yp5ixuFiMmM

Khanacademymedicine, Asthma Pathophysiology, 2014 August 6


[cited
2016
June
2]
[7:45
min]
Available
from:
https://www.youtube.com/watch?v=ZKvatbn4a_I

Health and Health News, What is Bronchial Asthma | What is


Asthma attack | Asthma Symptoms and Asthma Treatment, 2015
November 6 [cited 2016 June 2] [3:16 min] Available from:
https://www.youtube.com/watch?v=713S8Q1ghto

pg. 14

Others:

WordReference.com. Online Language Dictionaries: EnglishSpanish Dictionary [Internet]. Copyright 2016 [cited 2016 May 30]
Available from:
http://www.wordreference.com/es/translation.asp?traword

The Free Dictionary.com. Medical Dictionary [internet] Copyright


2003-2016 Farlex, Inc [cited 2016 May 30] Available from:
http://medical-dictionary.thefreedictionary.com/

Vocabulary:
DEVELOPING (en desarrollo): To become affected with a disease.
Patients with a family history of asthma and atopy are at significantly higher
risk of developing asthma.
RISK (riesgo): The probability that an event will occur.
Patients with a family history of asthma and atopy are at significantly higher
risk of developing asthma.
ELICITING (provocar): Any stimulus, conditioned or unconditioned, that
elicits a response.
Eliciting

symptoms

should

emphasize

characterizing

the

current

classification scheme that describes frequency per week, changes in


physical activity, diurnal variation, and seasonal variation.
TRIGGERS (desencadenante): An event that stimulates initiation of a
subsequent event or process.
It is more prevalent in children with a family history of atopy, and symptoms
and exacerbations are frequently provoked by a wide range of triggers
including viral infections, indoor and outdoor allergens, exercise, tobacco
smoke and poor air quality.
ENVIRONMENTAL (medioambiental): Pertaining to or emanating from the
environment.
Environmental irritants (perfume, tobacco smoke, wood-burning stoves)

pg. 15

SPIROMETRY (espirmetro): The measurement of the breathing capacity


of the lugs, such as inpulmonary function tests.
The diagnosis of asthma involves a thorough medical history, physical
examination, and objective assessments of lung function (spirometry
preferred).
ASSESSED (evaluar): To examine for the purpose of evaluation and/or
quality improvement.
The level of asthma control should be assessed at each visit, and
treatment should be tailored to achieve control. In most asthma patients,
control can be achieved through the use of both avoidance measures and
pharmacological interventions.
TAILORED (adaptado): Custom.
The level of asthma control should be assessed at each visit, and treatment
should be tailored to achieve control.
NEBULIZER (nebulizador): A divice for converting a drug in liquid from into
a mist or fine spray which is inhaled through a mask to provide medication
for respiratory system.
Usual initial treatment is with short-acting beta2 -agonist (albuterol)
administered by nebulizer or MDI/spacer. Nebulized albuterol (2.5 mg/3
mL); depending on response to therapy, this dose may be repeated at 20munite intervals for up to three times. Albuterol MDI/spacer 2-6 puffs;
depending on response to therapy, this dose may be repeated at 20-minute
intervals for up to three times.

pg. 16

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