Asthma and Smoking

Asthma and Smoking

John King, M. D. March 27, 2007

Asthma and Smoking

Asthma is a chronic inflammatory disease characterized by bronchial hyper reactivity and reversible airflow obstruction if treated.

Bronchial asthma is a condition of intermittent reversible airflow obstruction affecting only the airways, not the alveoli.

Complex molecular and cellular immunologic factors mediate asthma.

Immunologic factors include mast cells, eosinophils, thymphocytes, macrohsyes, neutrophils.

Asthma and Smoking Many people with asthma have concurrent

airway inflammation and airway hyperresponsiveness.

Asthma may occur in some patients after taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)

Severe airway obstruction may be fatal.

Asthma and Smoking

Asthma obstruction can occur in two ways.

1. Inflammation obstructs the lumen or the insides of the airways

2. Airway hyperresponsiveness results in airway obstruction by constricting bronchial smooth muscle, causing a narrowing of the airway from the outside

Assessment Information to obtain during history gathering phase

includes.

1. Pattern of episode of dypsnea, chest tightness, coughing, wheezing and excessive amounts of mucous production

2. When symptoms occur (e.g., continuously, seasonally, in association with specific activities, or more often at night) children with parents who smoke in the house are more likely to have nocturnal asthma.

3. Triggers include, carpet, animal inside the house, smells and roaches.

Assessment Clinical manifestations during

an asthma attack include 1. Audible wheezing upon expiration 2. Increased respiratory rate 3. Increased coughing if inflammation is

present. 4. Use of accessory muscles to assist in

respiratory effort 5. Muscle retraction at the sternum,

suprasternal notch, and between the ribs

Assessment

6. Barrel chest in patient with persistent or severe asthma (See Figure 30-3, p. 588)

7. Increased anterior-posterior (A-P) diameter of the chest

Assessment 8. Longer respiratory cycle, which requires

greater effort 9. Possible cyanotic nail beds and circumoral

cyanosis 10. Possibly unable to complete a sentence of

more than 5 words per breath 11. Pulse oximetry showing oxygen

desaturation 12. Hypoxemia evidenced by change in level

of consciousness and tachycardia

Assessment

Other assessment data includes 1. Arterial blood gases (ABGs) 2. Pulmonary function tests 3. Chest x-ray examination 4. Therapeutic levels of selected

medication

Assessment

Other allergic symptoms such as allergic rhinitis, skin rash, or pruritus may occur with atopic or allergic asthma.

Asthma and Smoking Lung and airway changes related to

aging is thought to be related to a change in the sensitivity of beta adrenergic receptors, which when stimulated relax smooth muscle and cause bronchodilation. As these receptors become less sensitive, that can no longer respond as quickly or strongly to naturally occurring agonist (epinephrine , dopamine) and beta-adrenergic medications

Considerations for Older People Asthma occurs as a new disorder in

about 3% of people over the age of 55. Another 3% of people over the age of 60

have asthma as a chronic disorder Three factors attributed to adult onset

asthma include:1. Longstanding untreated asthma

2. Smoking with a known history of childhood asthma3. Medication: (eg) Beta blockers, premarin and aspirin.

ASTHMA and Smoking Status Asthmaticus

Status asthmaticus is a severe, potentially life threatening acute episode of airway obstruction that tends to intensify once it begins and often does not respond to common therapy

1) Clinical manifestations include extremely labored breathing and wheezing, use of accessory muscles and distended neck veins.

2) The patient may develop a pneumothorax and cardiac or respiratory arrest

ASTHMA and Smoking Status Asthmaticus

Most smokers/ second hand smoke present to the ER with a more severe form of asthma: Status asthmaticus is treated with

intravenous fluids, systemic bronchodilators, steroids, epinephrine, and oxygen

The patient may require intubation If status asthmaticus is not reversed it may

lead to cor pulmonale, pneumothorax, and cardiac or respiratory arrest

ASTHMA and Smoking Interventions

The goal of therapy is to improve airflow, relieve symptoms, and prevent episodes by including the patient as a key partner in the management plan.


Patient education includes 1. How to assess symptom severity at

least twice daily with a peak flow meter

2. How to adjust medication (s) to manage inflammation and bronchoconstriction to prevent or relieve symptoms

ASTHMAInterventions

3. How to use symptom and intervention diary to learn his or her triggers of asthma attack symptoms, early cues for impending attacks, and personal response to medication

4. How to use a metered dose inhaler 5. How to determine when to consult the

health care provider

ASTHMAInterventions

Drug therapy includes bronchodilators, which increase bronchiolar smooth muscle relaxation. Bronchodilators have no effect on inflammation.

1. Short-acting beta2 agonist are more useful when an attack begins or as premedication when the client is about to enter an environment or begin an activity that is likely to produce an asthma attack

2. Long-acting beta2 agonist delivered by MDI directly to the bronchioles, are useful in preventing an asthma attack, but have no value during an acute attack.


3. Cholinergic antagonists allow for increased bronchodilation and decreased pulmonary secretions

4. Anti-inflammatory agents decrease the general allergic inflammatory responses in the airways; they may be administered systemically or as an inhalant (eg.) oral steroids, inhaled corticosteroids (ICS), theophylline

5. Corticosteroids decrease inflammatory and immune responses


6. Nonsteroidal inhaled anti-inflammatory agents are helpful in preventing an asthma episode.

7. Mast cell stabilizers prevent mast cell membranes from opening when an allergen binds to IgE; they are helpful for preventing symptoms of atopic asthma but not useful during an acute asthma attack

8. Leukotriene antagonists are used to prevent persistent asthma


Regular exercise, including aerobic exercise, is encouraged; the client’s exercise routine is adjusted to ensure that it does not trigger an episode-fro example , adjusting the environment in which the activity takes place

Supplemental oxygen with high flow rates or concentration may be used during an asthma attack.

ASTHMA and Smoking

National Heart, Lung, and Blood Institute/ American Thoracic Society/American Academy of Allergy, Asthma & Immunology (NHLBI/ATS/AAAAI) Task Force.

Proposed definition for asthma in order to standardize nomenclature for specific phenotypes of asthma.

Infection induced Asthma 1. New on set asthma

RSV, parainfluenza, metapneunovirus 2. Exacerbation

RSV, Rhinovirus, Influenza, parainfluenza, coronavirus. 3. Associated with persistent/chronic disease: Chlamydia pneumoniae, Mycoplasma pneumoniae adenovirus. 4.Biomarkers 1. Viral or bacterial cultures 2. Immunofluorescence 3. polymerase chain reaction from respiratory secretion 4. Serologic diagnosis

ASTHMA and Smoking

Allergic Asthma IgE- Medicated Asthma 1. +Allergen sensitization by one positive skin-prick test. 2. IGE sensitivity to specific environmental allergens, pollen, weeds, mites mold (Aspergillus), and pet dander. 3.Childhood onset asthma, allergic rhinosinusitis, and symptom provocation by environmental triggers. 4. Exercise related symptoms 5. Sinusitis and nasal polyps

ASTHMA and Smoking

Biomarkers:1. Peripheral eosinophilia

2. Elevated IGE in serum

3. Th2-type cytokines (T-helper type 2 lymphocyte)

4. Mast-cell markers

ASTHMA and Smoking

Non-allergic Asthma1. Diagnosis already confirmed 1. Negative skin prick or RAST ( radioallergosorbent test) testing seasonal and perennial allergens

2. Normal to Low IGE 3. No history of triggers or seasonality 4. Adulthood asthma 5. No sensitivity to aspirin

Biomarkers:

1. Low or normal total IGE levels2. Mucosal IGE synthesis or tissue eosinophilia

ASTHMA and Smoking

Definition of Aspirin-Sensitive Asthma

1. Documented asthma is in response to asthma 2. Probable aspirin sensitivity if sinus disease or nasal polyps3. >age 20

Biomarkers:

1. Increase levels of urine leukotrienes ( eg, Leukotriene E4)2. CT scanning pansinusitis or nasal polyps3. Aspirin or lysine-aspirin challenge

Asthma and Smoking

Relationship of Smoking and Cancer of The Lung by: Alton Ochsner, M.D.

Annual consumption of cigarettes per capita in the U.S. in persons 15 years and older.

Asthma and Smoking

Annual Consumption Cigarettes Per capita in U.S. in Persons 15 Years and Older

630

3500

0

500

1000

1500

2000

2500

3000

3500

4000

1920 1953 U.S. Dept. Agriculture 1953

Cigarettes Per capita in

U.S.

Asthma and Smoking

Female - Lung Cancer Deaths in U.S

0.6

2.1

4.3

0

12

34

5

1914 1930 1950

per

100

0,00

0 p

op

ula

tio

n

Relationship of Smoking and Lung Cancer by Alton Ochsner, M. D. The American Surgeon

Vol. 21, 1955

Asthma and Smoking Male - Lung Cancer Deaths in U.S

19.6

3.60.70

5

10

15

20

25

1914 1930 1950

per

1000

,000

po

pula

tion


Vol. 21, 1955

Asthma and Smoking

Death From Cancer of Lung in White Males In U.S.

5.3

27.1

0

5

10

15

20

25

30

1930 1948

per

100

,000

po

pu

lati

on


Vol. 21, 1955

411%Increase

Asthma and Smoking

Nicotine in Cigarettes up 10% from 1998 to 2004 Minority – Aimed Brands tally Highest Amount 1. Marlboro

2. Kool Menthol Lights Newport menthol filter 100’s and Camel nonfilters were tied for

the highest nicotine at 2.9 milligrams. And rose to 3.2 milligrams .

The Washington PostBy David BrownAugust 31, 2006

Asthma and Smoking

Is The Public Health Message On Secondhand Smoke Based On Science?

No, it’s driven by politics, not good science. Stated by Jerome C. Arnett Jr., M.D.

Public health messages are based on solid evidence. Stated by Peter Tuteur, M.D.

Internal Medicine NewsFebruary 15, 2007

Asthma and SmokingSecondhand Smoking

Secondhand smoke is called: Passive Involuntary Secondhand smoking The non-smoker breathes “Sidestream” smoke from the burning tip of the cigarette. “Mainstream” smoke that has been inhaled and then exhaled by

the smoker.Secondhand Smoke (SHS) Is a major source of indoor air pollution.


Tobacco Smoke Contains over 4000 chemicals in the form of particles and gases.

85% of the smoke in a room results from sidestream smoke . Particulate phase includes tar (itself composed of many chemicals) nicotine, benzene and benzo(a)pyrene. Gas phase includes carbon monoxide, ammonia. dimethylnitrosamine,

formaldehyde, hydrogen cyanide and acrolein. Some of these are marked irritant properties and are known or

suspected carcinogens (cancer causing substances). The Environmental Protection Agency (EPA) in the USA has classified

environmental tobacco smoke as a class A (known human) carcinogen along with asbestos, arsenic, benzene and radon gas,


Secondhand Smoke Definition

Environmental tobacco smoke (ETS) is a mixture of the smoke given off by the burning end of a cigarette, pipe or cigar .

It is involuntarily inhaled by nonsmokers


Environmental Protection Agency (EPA) classified secondhand smoke as:

Known cause of cancer in humans Causes disease and premature death in children and

adults who do not smoke. Causes approximately 3400 lung cancer deaths and

22,700 - 69,600 heart disease deaths in adult nonsmokers in the U.S. each year.


Approximately 26 % of adults in the United States currently smoke cigarettes, and 50% to 67% of children under five years of age live in homes with at least one adult smoker.


Exposure Environmental Tobacco Smoke (ETS) Decreases lung efficiency and impairs lung function

in children of all ages. Increases both the frequency and severity of

childhood asthma. Aggravate sinusitis, cystic fibrosis, and chronic

respiratory problems such as cough and postnasal drip.

Increases the number of children’s colds and sore throats.

ETS exposure increases the likelihood of bronchitis and pneumonia.


Scientific Committee on Tobacco and Health (SCOTH)

Recent reviews by SCOTH found that the conclusions of its initial report still stand i.e. that there is a “causal effect of exposure to secondhand smoke on the risks of lung cancer, ischaemic heart disease and a strong link to adverse effects in children”

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Asthma and Smoking