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1

Things we always have to ask about in the history to diagnose asthma?

Coughing! Always have to ask about a night time cough. Wheezing too but not always present

2

How would we set up successful management of asthma?
4

1. Routine monitoring of lung function
2. Patient education
3. Environmental factors (avoid triggers)
4. Pharm (taper down or taper up step wise approaches)

3

What is asthma?

A chronic inflammatory disorder of the airways.

4

Kids with what kind of symptoms often test positive for asthma?
3

children with atopy/eczema risk factors for asthma. obesity- sleep apnea also would cause asthma exacerbations by increasing chronic inflammation

5

Definition of asthma?
3

A complex disorder characterized by variable and recurring symptoms,
1. airflow obstruction,
2. bronchial hyperresponsiveness and an
3. underlying inflammation.

6

What are the three things that cause airflow limitations?

Bronchoconstriction

Airway hyperresponsiviness

Airway edema

7

Describe the following:
Bronchoconstriction

Airway hyperresponsiviness

Airway edema

---Bronchial smooth muscle contraction in response to exposure to a variety of stimuli

---Exaggerated bronchoconstrictor response to stimuli

---Edema, mucus hypersecretion, formation of thickened mucus plugs

8

Asthma is characterized by episodic, reversible _____ resulting from an exaggerated ______ ______ to various stimuli.

bronchospasm

bronchoconstrictor response

9

Symptoms patterns for asthma can vary. Describe how they can present?
4

1. Perennial versus seasonal
2. Continual versus episodic
3. Duration, severity and frequency
4. Diurnal variations (nocturnal and early morning)

10

Inflammatory response involves multiple players

The trigger or stimulus may be exposure to intrinsic or extrinsic host factors such as?

Eosinophils

Lymphocytes

MAST Cells


11

Describe the following in how they affect asthma pts:

Eosinophils?

Lymphocytes?

MAST Cells?

-- release granular protein that damages bronchial epithelium and promotes airway hyper-responsiveness. (allergic and parasites)

-- produce Cytokenes, Leukotriene B-4 and C-4, prostaglandin and histamine. (viral)

-- initiate arousal condition in IgE receptors

12

What are leukotrienes?

How do they work in exacerbating asthmatics?
5

Potent Inflammatory Mediators

1. Increased vascular permeability /edema
2. Increased mucus production
3. Decreased mucociliary transport
4. Inflammatory cell recruitment i.e. eosinophils—release inflammatory mediators i.e. cationic proteins
5. LTD4: profound bronchoconstriction, about 1000 x more potent than histamine

13

Describe the early phase of an asthma exacerbation?
2

1. IgE is secreted by plasma cells, binds to receptors on mast cells and basophils
2. Mast cells release mediators that contract airway smooth muscle directly

14

Describe the late phase of an asthma exacerbation?
3

1. Recruitment of inflammatory and immune cells, including the eosinophil, basophil, neutrophil, and helper, memory T-cells to sites of allergen exposure.
2. Dendritic cells are also recruited and play an important role.
3. The late phase reaction is more complex than just causing smooth muscle contraction.

15

What is the difference between instrinsic and extrinsic asthma?

Etiology?
Onset?
Genetic?

Intrinsic:
1. Considered non-immune
Serum IgE levels are normal
2. Usually develops in later life
3. Usually no personal or family hx


Extrinsic:
1. Type-1 Hypersensitivy reaction
-Associated with other allergic manifestations
2. Onset is usually the first two decades of life
3. Family history

16

Stimuli that have little or no effect in normal subjects can trigger bronchospasm in intrinsic asthmatics. What are examples of these?
8

1. ASA
2. Pulmonary infections (especially viral)
3. Cold
4. Psychological stress
5. Exercise
6. Inhaled irritants
7. GERD
8. Post nasal drip

17

What is samters triad?

aspirin, allergy/ rhinitis, nasal polyps

18

What is usually elevated in extrinsic asthma pts?
2

Serum IgE and eosinophil count are usually elevated

19

Occupational asthma and
Allergic bronchopulmonary aspergillosis are categorized as what kind of asthma?

extrinsic

20

What is exercise induced asthma?

Can be found in asthmatics, patients with the following types:
3


Treatment?
2

Exercise or vigorous physical activity triggers acute bronchospasms in persons with heightened airway reactivity.

Can be found in asthmatics, patients with
1. atopy,
2. allergic rhinitis, or even
3. healthy persons

1. Beta-Agonist 10-15 minutes before activity
2. Avoid activity in cold air if possible

21

Classic triad of symptoms
in asthmatics?

1. Persistent wheeze, end expiratory wheeze
2. Chronic episodic dyspnea
3. Chronic cough

22

Associated Symtpoms in asthmatics?
7

1. Tachypnea, tachycardia, and systolic hypertension
2. Audible harsh respirations, prolonged expiration, wheezing
3. Sputum production (yellow sputum is probably underlying asthma)
4. Chest pain or tightness
5. Hemoptysis (pretty rare)
6. Diminished breath sounds during acute exacerbations
7. Pulses paradoxus (pulse rate changes with inspiration and expiration)- asthma, tamponade, pericarditis, sleep apnea. systolic blood pressure change and pulse change

23

What should we ask about the timing of these symtpoms?

Symptoms may be worse or only present at night

24

What should be in our diff for asthma?
12

1. COPD (usually in older pts)
2. Anaphylaxis
3. Foreign body ingestion
4. Congestive heart failure
5. Pulmonary embolism
6. Panic disorder, hyperventilation syndrome
7. Pneumonia, bronchitis
8. Alpha1-Antiprypsin Deficiency (leads to COPD)
9. GERD
10. Sarcoidosis (thickening of the lungs)
11. Vocal Cord Dysfunction
12. Cough secondary to drugs (ACE inhibitors)- lisinopril

25

With hemoptysis, should consider:
4

1. Allergic bronchopulmonary aspergillosis
2. Bronchiectasis (cystic fibrosis)
3. Lung carcinoma
4. TB

26

Indicators for considering a Dx of Asthma:
4

1. Wheezing
Any history of:
2. Cough (worse particularly at night)
3. Recurrent wheeze
4. Recurrent difficulty in breathing, recurrent chest tightness

27

Indicators for considering a Dx of Asthma:
Symptoms occur or worsen in the presence of?

7

1. Exercise
2. Viral infection
3. Inhalant allergens and irritants
4. Changes in weather
5. Strong emotional expression (crying, laughing)
6. Stress
7. Menstrual cycles

28

What is needed to establish an asthma diagnosis?

spirometry

29

PFT results for asthma pts will show?

FEV1?
FEV1/FVC?
Inflation will be?

What FEV1 change shows reversibility?

Obstructive disease that is reversible

Decreased FEV1 less than 80% predicted
FEV1/FVC less than 65%
Hyperinflation

Establish reversibility
FEV1 increase of > or = 12% and at least 200ml after using a short acting B2 agonist.

30

Provocation testing with Methacholine or histamine
will show us what?
3

1. Detects bronchial hyperactivity
2. Supports the dx of asthma
3. Sometimes done when asthma is suspected but PFT’s are near normal.