Female Bronchial Asthma

• Dr Muhammad El Hennawy• Ob/gyn Consultant• Rass el barr central hospital and dumyat specialised hospital• Dumyatt – EGYPT• www. mmhennawy.co.nr

Diseases of chest• COLD----Chronic obstructive lung disease reversible (bronchial asthma ) Irreversible (chronic bronchitis – chronic obstructive

emphysema) Reversible and irreversible — asthmatic bronchitis• SLD (supurative lung diseases) Bilateral---bronchiectasis --- infected systemic lung Unilateral---lung abscess --- empyema• Syndrome of multiple negative – pleural thickning, Pleural effusion ,lung fibrosis

Definition Of Asthma

• It is reversible chronic obstructive lung disease , characterized by recurrent episodes of wheezing, chest tightness, and coughing alternating with periods of relatively normal breathing.

. Asthma symptoms can occur spontaneously or may be triggered by allergens, environmental factors, exercise, cold air, infections, and stress.

there is strong evidence that estrogen and progesterone may actually improve lung

function and asthma• Progesterone has been shown to suppress

the immune system and so in that sense it's protective or helpful. It may reduce the increased inflammation that's occurring.

• both progesterone and estrogen have been found to reduce constriction of the airways and relax the bronchial smooth muscle in the airways

Asthma

premenstrual

menestrual

OCPs

pregnancymenopause HRT

delivery

Breast feeding

• hormone levels are lower during the premenstrual and menstrual phases--asthmatics have been found to experience an increase

• Oral contraceptives, which really dampen and smooth out these fluctuations in hormone levels, have been found to improve pulmonary function in some women as well.

• women move through and into the menopausal period because at this time estrogen, progesterone also rapidly decrease -- experience an increase

• hormone replacement therapy in asthmatic menopausal women have better pulmonary function and less pulmonary obstruction but the increased risk of asthma to HRT on the basis of an observational study in healthy menopausal women

Menstruation and asthma• Asthma is more common in boys than in girls before

puberty, but then girls "catch up," suggesting a possible hormonal

influence initiating the onset of asthma at menarche • asthma symptoms can begin to worsen from three to seven

days before the onset of menses(premenstrual asthma), and can last until the bleeding ceases (menestrual asthma)

• half of cases the woman's attack struck within four days of the start of her menstrual period.

• one-third of women think their symptoms are worse just before or during menstruation.

Contraceptive pills and asthma Oral contraceptives, which really dampen and

smooth out these fluctuations in hormone levels, have been found to improve pulmonary function in some women as well

• Some women who use birth control pills may have greater difficulty controlling their asthma. (pill asthma)

Menopause and asthma• Variations in asthma presentation have been

observed during the time when serum estradiol levels decreased sharply after a prolonged peak. These findings suggest that these monthly variations in this hormone may influence the severity of asthma in women.

• The changing hormone levels of menopause may cause some women to develop asthma for the first time; others may experience worsening symptoms

Hormone replacement therapy (HRT) and asthma

• hormone replacement therapy in asthmatic menopausal women have better pulmonary function and less pulmonary obstruction

• but the increased risk of asthma to HRT on the basis of an observational study in healthy menopausal women

Ashtma with pregnancy, delivery,postpartum and

breast feeding

Incidence

• 7 percent of women in their childbearing years • 4 percent of all pregnancies .• It can cause serious complications for both mother

and child if not controlled properly during pregnancy.

• The good news is that asthma and allergies can be controlled, and when they are, the risks to mother and baby are extremely low.

causes • allergen exposure --dust mites, cockroaches, and animal danders. pollens,

molds, pet dander, house dust mites and cockroaches • Other non-allergic substances also may worsen your asthma and allergies.

These include tobacco smoke, paint and chemical fumes, strong odors, environmental pollutants (including ozone and smog) and drugs, such as aspirin or beta-blockers (used to treat high blood pressure, migraine headaches and heart disorders).

• Chronic sinusitis ---the bacteria, toxins, and inflammatory mediators contained in aspirated nasal secretions irritate the mucosa of the lower airways of asthmatic patients, thereby worsening the control of their reactive airway disease

• Gastroesophageal reflux disease (GERD) is commonly associated with asthma. GERD can cause worsening of asthma by either a vagally mediated mechanism or direct aspiration of acidic gastric contents into the respiratory tree

• exacerbated by stress and anxiety • Aspirin and nonsteroidal anti-inflammatory drugs can cause bronchospasm

in some patients with asthma • . Hormonal factors (ie, menses, use of exogenous hormones by female

patients, and hyperthyroidism) also can exacerbate asthma

• The muscles of the bronchial tree become tight • the lining of the air passages become swollen, reducing

airflow and producing the wheezing sound • Mucus production is increased.

pathophysiology

Diagnosis and Monitoring• objective measurements are important in evaluation of

difficult-to-manage cases objective evidence of airflow obstruction (a tightness in

chest and wheezing, shortness of breath and/or coughing. )that is reversible either spontaneously or through treatment with a bronchodilator

• Because both patient and physician may have a poor perception of the severity of the patient's asthma,

Spirometric measurement at each office visit or routine use of a peak flow meter by the patient is needed to confirm the effectiveness of the treatment strategy.

• A peak flow meter• at home • the convenience and ease of use • measure the PEFR (peak expiratory

flow rate) by taking a deep breath and then blowing into a tube on the meter as hard and as fast as patient can.

• every day, sometimes several times a day, and keep track of these rates over time --are compared with charts that list normal values for sex, race, and height.

• A spirometer• in a doctor's office • gives a more accurate measure of lung

function • diagnose asthma, classify its severity, and help

decide what is the best way to treat asthma • done periodically • The total volume patient exhale is called

"forced vital capacity," or FVC• measures the volume of air patient exhale in

the first second. (This is referred to as "forced expiratory volume in one second," or FEV1.)

• Patient will be given a bronchodilator and repeat the measerment

•You would not consider managing hypertension without a sphygmomanometer, or diabetes without a glucometer –

• accurate and objective assessmentand management  of asthma is not possible without a spirometer or peak flow meter

The effect of asthma on pregnancyspecially if untreated well

• MATERNAL• Increase emergency department

visits, • Increase hospitalizations,• Increase Hyperemesis• Increase vaginal hemorrhage and accidental haemorrhage due

to severe coughing• Increase CS • Increase respiratory failure, • Increase high blood pressure and preeclampsia, • Increase death..

• FETAL• increased low birth weight, • Increase premature delivery, • Increase fetal demise• NEONATAL• Increase neonatal hypoxemia • low newborn assessment

scores• increased perinatal mortality

The effect of pregnancy on asthma• Some patients experience an improvement of their symptoms

during pregnancy; The exact reason for this is unknown, but the increase in the body's cortizone level during pregnancy may be an important cause of the improvement which can occur. Many women experience less asthma during the last four weeks of pregnancy. This may be due, in part, to the increase of prostaglandin E reported to occur during this time period of pregnancy, or it may be that the "dropping" of the baby in the final weeks of pregnancy takes pressure off the lungs, resulting in easier breathing

• others have increased symptoms; . Some women experience gastroesophageal reflux causing belching and heartburn. This reflux, as well as sinus infections and increased stress, may aggravate asthma. Asthma has a tendancy to worsen during pregnancy in the late second and early third trimester.

• and some see no noticeable change in their asthma at all.

During delivery • Only about 1 in 10 women with asthma have

symptoms during delivery. • Most asthmatic women are even able to perform the

Lamaze breathing techniques during delivery without difficulty.

• The increase in plasma epinephrine that occurs during labor and delivery may contribute to the absence of asthma symptoms during this critical time period

postpartum and asthma

• If you've been pregnant before, you can probably expect your asthma to behave the same way in subsequent pregnancies. Within three months of your baby's birth, your asthma probably will return to the way it was before you became pregnant.

Breastfeeding and asthma• there is some evidence to suggest that

breastfeeding may reduce the risk of your baby developing asthma

• child has a one in ten chance of inheriting the condition from its mother, which rises to one in three if both parents have asthma. But a recent long-term study showed that breastfeeding for the first six months of life significantly reduces the risk of the child's developing allergic breathing problems by age 17, compared to babies who are breastfed for less than six months.

The goal of asthma therapy during pregnancy

• It is virtually the same as in non-pregnant patients.• The goal is ---to prevent hospitalization ----and emergency room visits -----as well as lost time at work and chronic

disability.

Since the symptoms associated with asthma and allergies can vary from day to day, month to month, or season to season, regardless of pregnancy, treatment plan will be based on the severity of disease and previous experience using specific medications during pregnancy

PreventionDecrease or control exposure to known allergens and

irritants by staying away from cigarette smoke, exposure to pets

removing animals from bedrooms or entire houses, and avoiding foods that cause symptoms. Alcohol should be doubly avoided by the pregnant

woman with asthma, because it can harm the developing fetus and because it can cause bronchial constriction as it is exhaled through the lungs

Allergy desensitization is rarely successful in reducing symptoms

If a patient tests allergic to a specific trigger, allergists-immunologists recommend the

following avoidance steps Remove allergy-causing pets from the house. • Seal pillows, mattresses and box springs in special dust

mite-proof casings (your allergist should be able to give you information regarding comfortable cases).

• Wash bedding weekly in 130 degrees F water (comforters may be dry-cleaned periodically) to kill dust mites.* Keep home humidity under 50 percent to control dust mite and mold growth.

• Use filtering vacuums or "filter vacuum bags" to control airborne dust when cleaning.

• Close windows, use air-conditioning and avoid outdoor activity between 5 a.m. and 10 a.m., when pollen and pollution are at their highest.

Monitoring• The pregnant asthmatic should be monitored carefully and the

selection of medications should be reviewed by a specialist. • Doctors are very cautious about the use of drugs during the first three

months of pregnancy• even though most anti-asthmatic medications are considered safe

during pregnancy. • The medications do not appear to be associated with increased

congenital malformations, nor is there is any evidence that anti-asthmatic drugs (theophylline, beta agonists, cromolyn sodium, or steroids) will adversely affect a nursing infant. the potential risks of asthma medications are lower than the risks of uncontrolled asthma, which can be harmful to mother and baby.

• As long as the asthma is controlled, the pregnancy and its outcome do not appear to be adversely affected by the mother taking cortisone (steroids) orally or by inhalation.

• Aerosols and sprays are preferable to oral medication• Time-tested older medications are preferred

Self-management of asthma outpatient management of asthma

• Teach the patient self-management (Level of Evidence=A;• The patient should have good knowledge of self-management.• The components of successful self-management are acceptance of

asthma and its treatment effective and compliant use of drugs• a PEF meter and follow-up sheets at home• written instructions for different problems• As a part of controlled self-management the patient can be given • a PEF follow-up sheet with individually determined alarm limits

and the following instructions (Level of Evidence=B;• If the morning PEF values are 85% of the patient´s earlier

optimal value, the dose of the inhaled corticosteroid should be doubled for two weeks.

• If the morning PEF values are below 50 - 70% of the optimal value the patient can start a course of prednisolon 40 mg daily for one week and contact the doctor by telephone.

Treatment ProtocolDIAGNOSIS BASED ON SYMPTOMS & OBJECTIVE ASSESSMENT

ASSESS SEVERITYMILD MODERATE SEVERE

ENVIRONMENTAL CONTROL AND EDUCATION

ADDITIONAL THERAPY

INHALED CORTICOSTEROIDS

INHALED SHORT-ACTING BETA2-AGONIST PRN

New Asthma Treatment AlgorithmNew Asthma Treatment Algorithm

Categories of medication• 1. "Relievers" (for intermittent symptoms) -short-acting ß2-agonists

– -ipratropium (rarely)

• 2 ."Controllers" (maintenance therapy) ---anti-inflammatory medications

• -inhaled/oral glucocorticosteroids• -leukotriene receptor antagonists• -anti-allergic agents (cromoglycate, nedocromil)

----bronchodilators• -long-acting inhaled ß2-agonists (salmeterol,formoterol)• -theophylline• -ipratropium

. .

Working Group Recommendations for the Pharmacological Step Therapy of Chronic Asthma During Pregnancy

CategoryFrequency/Severity of Symptoms (sx)

Pulmonary Function* (untreated)

Step Therapy

Mild intermittentSx<=2 times per weekNocturnal Sx <=2/monthExacerbations brief (a few hours to a few days)Asymptomatic between episodes

=>80%Normal function between episodes

Inhaled beta2-agonists as needed (for all categories) 

Mild persistentSx > 2 times per week but not daily.Nocturnal Sx > 2/monthExacerbations may affect activity

>=80%Inhaled cromolynSubstitute inhaled beclomethasone if not adequate

Moderate persistent

Daily SxNocturnal Sx > 1/week.Exacerbations affect activity

60-80%Inhaled beclomethasoneAdd oral theophylline

Severe persistentContinual SxLimited activityFrequent nocturnal symptomsFrequent acute exacerbations

<60%Above + oral corticosteroid(burst for active symptoms, alternate day or daily if necessary)

Inhaled Steroids• The best option for initial anti-inflammatory treatment (Level I) • initial daily dose: 400-1000 µg BDP or equivalent (Level III)• initial daily dose in children: 200-1000 µg BDP or equivalent (Level IV)• once best results are achieved, reduce dose to minimum required for control (Level

III)• use a spacer with MDI delivery (Level I)• Low to moderate doses provide the best risk-benefit profile (Level I)• Adults using high doses should consider bone densitometry (Level III• monitor IOP in glaucoma patients (Level V)• avoid getting aerosolized steroids in the eye (Level V)• regular users should rinse after use (Level I)• patients requiring consistent high doses should be referred (Level IV)

Leukotriene receptor antagonists

• may be considered as an alternative to increased doses of inhaled steroids as add-on therapy to glucocorticosteroids (Level II)

• There is insufficient data to recommend LTRAs for regular therapy in place of inhaled glucocorticosteroids (Level IV)

Cromoglycate • should not be added to an established regimen of

inhaled / systemic steroids (Level I)• may be used as a less effective alternative to short-

acting ß2-agonists to prevent exercise-induced symptoms (Level I)

• may be an alternative to low-dose IHS in children with mild symptoms (Level I) unwilling to take inhaled glucocorticosteroids

• may be used for short-term allergen exposure (Level I)

Nedocromil • is not recommended for first line therapy of asthma• may be considered as a less effective alternative to

short-acting ß2-agonists to prevent exercise-induced bronchospasm (Level I)

• may be a modestly effective alternative to low-dose inhaled glucocorticosteroids in children with mild symptoms (Level I)

Theophylline • not recommended as 1st-line therapy (Level I)• may be used as an alternative to increased doses of

inhaled glucocorticosteroids (Level II)• dose must be titrated slowly (Level III) because of

the narrow therapeutic range and the potential for severe side effects

Anticholinergic bronchodilators

• not recommended as 1st-line therapy except in patients who cannot tolerate ß2-agonists (Level III)

long-acting inhaled ß2-agonists (salmeterol,formoterol)

• These work in the same way as the ordinary relievers such as salbutamol and terbutaline, with the difference that they stick to the cells in the body on which they act, and so work for much longer. The side-effects are the same, namely tremor, increased pulse rate, and palpitations ,They have been introduced much more recently, but no hazards in pregnancy are known.

Other therapies• in chronic severe asthma unresponsive to moderate doses of oral

glucocorticosteroids confounding factors should be assessed before increasing therapy

• patients who need regular oral glucocorticosteroids should be referred to a specialized centre (Level III) and should receive prophylactic osteoporosis treatment (Level I)

• immunosuppressive agents should be reserved for patients dependent on long-term high-dose glucocorticosteroids (Level III) followed in specialized centres

• no apparent benefit for most unconventional therapies: acupuncture, chiropractic, homeopathy, naturopathy, osteopathy, herbal remedies (Level I to III, depending on the therapy)

Other treatments for asthma• Antihistamins Antihistamines have very limited effect in asthma (Level of

Evidence=B; They can be used to alleviate other symptoms of allergy.• Antibiotics Only clear signs of bacterial infection are an indication for antibiotics. Most infections causing exacerbations of asthma are of viral origin.

Remember sinusitis, but avoid unnecessary antibiotics.• Antitussives Cough is usually a sign of poor control. Increase the intensity of treatment, or give a short course of oral corticosteroids.

Delivery devices• inhaled drug delivery is recommended for ß2-agonists and

glucocorticosteroids (Level I)• use the inhalation device that best fits the need of the individual

(Level III)• health professionals must teach technique when devices are

dispensed (Level I)• patients' technique must be reassessed and reinforced at each contact

(Level II)• HFA-propellant devices are recommended over CFC devices (Level

IV)-- CFC-free inhalers use hydrofluoroalkanes (HFAs) as the propellant. HFAs are less likely to affect the ozone layer.

• home wet nebulizers rarely indicated (Level III)• in children, conversion from mask to mouthpiece is strongly

encouraged (Level II)• spacers recommended in certain patients especially in those on high

dose IHS (Level I)• MDIs with spacers for children <5 (Level II)-- Metered Dose

Inhalers• dry-powder inhalers adequate for age 5+ (Level II) -- They are dry

powder devices and do not contain a propellant.

Related evidences

Levels of evidence (based on AHCPR 1992).

Ia  Evidence obtained from a meta-analysis of RCTsIb  Evidence obtained from at least one RCTIIa Evidence obtained from at least one well-designed, controlled study without   randomisationIIb Evidence obtained from at least one other type of well-designed   quasi-experimental studyIII Evidence obtained from well-designed, non-experimental, descriptive studies, such as comparative studies, correlation studies and case-control studiesIV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

Related evidence 1• Antileukotienes alone are less effective than inhaled steroids for improving lung function and

quality of life (Level of Evidence=B;

• There is not enough evidence to evaluate the benefits of influenza vaccination in patients with asthma (Level of Evidence=D;

• Physical training in patients with asthma improves cardiopulmonary fitness but does not change lung function (Level of Evidence=B;

• There is limited evidence that breathing exercises may be of some benefit in asthma (Level of Evidence=C;

• Methotrexate may have a small steroid sparing effect in adults with asthma who are dependent on oral corticosteroids (Level of Evidence=B;

• Use of cyclosporin may reduce the need of oral steroids in asthma but side effects are common (Level of Evidence=C;

• Gold may reduce the need of steroids in asthma, but given the side effects and necessity for monitoring the treatment cannot be recommended (Level of Evidence=C;

• Use of limited asthma education as it has been practiced does not appear to improve health outcomes (Level of Evidence=C;

Related evidence 2• There is no overall improvement of asthma following treatment of gastro-

oesophageal reflux (Level of Evidence=C;

• There is insufficient evidence to assess the benefits of different ways to organise asthma care(Level of Evidence=D;

• Inhaled corticosteroids are as effective as a daily dose of 7.5 to 10 mg or prednisolone, probably with fewer adverse effects (Level of Evidence=B;

• Inhaled beclomethasone has a small dose-response effect (Level of Evidence=B;

• There is no conclusive evidence of differences in relative efficacy between beclomethasone and budesonide, although there is some data to suggest that BUD via Turbohaler is moreeffective than BDP via either Rotahaler of metered dose device (Level of Evidence=B;

• Doses of fluticasone in the range of 100 µg to 1000 µg are more effective than placebo in the treatment of asthma, low doses being almost as effective as high doses in mild-moderate asthma (Level of Evidence=A;

Related evidence 3• Higher potency compounds such as fluticasone may be more effective, but

there is an excess of systemic activity with fluticasone propionate compared with other inhaled corticosteroids when therapeutically effective doses are compared (Level of Evidence=A;

• Nedochromil sodium is as effective as cromoglycate for exercise-induced asthma (Level of Evidence=B;

• There is insufficient evidence to compare the effectiveness of holding chambers versus nebulisers in chronic asthma (Level of Evidence=D;

• There are no significant differences for any important outcomes between standard CFC containing pMDI and other devices in the delivery of beta-2 agonist for non-acute asthma (Level of Evidence=A;

• In patients under 60 years of age there is no evidence of an effect of inhaled corticosteroids at conventional doses given for two or three years on BMD or vertebral fractures (Level of Evidence=B;

• There is some evidence that macrolides may be beneficial in some subgroups of asthmatic patients, but further studies are needed (Level of Evidence=D;

• There is no evidence to support the use of dehumidification for asthma patients (Level of Evidence=D;

• lBreathing techniques including slow deep breathing, physiotherapy, respiratory muscle strengthening, and yoga breathing exercises, are not proven to be effective for asthma (Level of Evidence=C;

Follow-up• Because asthma is a common disease it should be

mainly treated and followed up by a general practitioner.

• A patient on medication should meet his own doctor regularly.

• In mild cases one follow-up appointment yearly is sufficient.

• A two-week measuring of PEF values at home is usually sufficient as follow-up examination,eventually complemented by a simple spirometer examination.

Expectations (prognosis)

• Asthma is a disease that has no cure. • With proper self management and medical

treatment, most people with asthma can lead normal lives.

“Dyspnea of pregnancy"

• The important physiologic changes that happen during pregnancy include some changes in the cardiopulmonary system. Beginning in the first trimester and continuing throughout pregnancy, mothers experience some "dyspnea of pregnancy" whether or not they have asthma; elevated progesterone levels stimulate increased breathing depth and relative hyperventilation. Additionally, oxygen consumption is increased during pregnancy