Faegh Aderangi

Tarek Hassouna
Asthma
The lack of air is so refreshing…
 Asthma
• Defined by following triad:
– Airway inflammation
– Airway hyper responsiveness
– Reversible airflow obstruction

• Asthma can begin at any age

 The Underlying Mechanism
Risk Factors (for development of asthma)

INFLAMMATION

Airway
Hyperresponsiveness Airflow
Limitation

Symptoms-
Risk Factors (shortness of breath,
(for exacerbations) cough, wheeze)
Asthma: Pathological changes
 Types of Asthma
• Extrinsic vs. Intrinsic Asthma

– Extrinsic
• Atopic Pt (IgE produced in response to
environmental antigens)
– May be associated with eczema and hay fever
• Pt become asthmatic at a young age
– Intrinsic
• Not related to atopy or environmental triggers
• Clinical Features
– SOB, wheezing, chest tightness, and cough
– Sx vary in severity and may not occur
simultaneously
– Onset: 30 mins after exposure to triggers
– Sx typically worse at night
– Wheezing (inspiratory + expiratory)
• Most common finding on PE
 Classification of Asthma Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Nighttime
Symptoms PEF
Symptoms
STEP 4 Continuous
<60% predicted
Severe Limited physical Frequent
Variability >30%
Persistent activity
STEP 3 Daily >60%-<80%
Moderate Use 2-agonist >1 time week predicted
Persistent daily; Daily activity Variability >30%
STEP 2 >80% predicted
>1 time a week
Mild >2 times a month Variability 20-30%
but <1 time a day
Persistent

STEP 1 < 1 time a week

Asymptomatic >80% predicted
Intermittent <2 times a month
and normal PEF Variability <20%
between attacks

The presence of one of the features of severity is sufficient to place a

patient in that category.
• “All That Wheezes Is Not Asthma”
– CHF
• Airway edema and congestion of bronchial mucosa
– COPD
• Inflamed airways may be narrowed or bronchospasm
may be present.
– Cardiomyopathies
• Edema around the bronchi
– Lung cancer
• Central/Mediastinal tumors obstructing airways
• Signs of acute severe asthma attack
– Tachypnea
– Diaphoresis
– Wheezing
– Speaking in incomplete sentences
– Using accessory muscles of respiration
– Paradoxical movement of abdomen & diaphragm
on inspiration seen in impending respiratory
failure
 Diagnosis
• PFTs
– Decreased expiratory flow rates, FEV1, and FEV1/FVC (<0.75)
• Spirometry
(BEFORE and AFTER bronchodilator)
– increased FEV1/FVC, at least 12%
• Peak flow
• Normal: 450-650 L/min (men) 350-500 L/min (women)
• Mild: >300
• Moderate to severe: 100-300
• Severe: <100
 Diagnosis
• Bronchoprovocation test
– If asthma is suspected but PFTs are
nondiagnostic
– Measures lung function BEFORE and
AFTER inhalation of methacholine
– Hyperresponsive airways develop
obstruction at lower doses.
 Diagnosis
• CXR
– Normal in mild cases
– Hyperinflation in severe cases
– Indicated in severe asthma cases
to exclude other conditions
• Pneumonia
• Pneumothorax
• Pneumomediastinum
• Foreign Body
 Diagnosis
• Arterial Blood Gases (ABG)
– Indicated in severe respiratory distress
• Hypocarbia is common
• Hypoxemia may be present

– If PaCO2 is normal or increased respiratory failure may

ensue
• Asthma attack  increased respiratory rate  decreased PaCO2.
• If PaCO2 is increasing  respiratory muscles are either fatigued or
airway obstruction exists
• Pt should be hospitalized with mechanical ventilation considered.
 Treatment
• Inhaled B2-agonists
– Short acting
• Indication: Acute Attack (rescue)
• Rx: Albuterol
• Onset: 2-5 mins
• Duration: 4-6 hrs
– Long acting
• Indication: Nighttime / Exercise-induced asthma
• Rx: Salmeterol
 Treatment
• Inhaled Corticosteroids
– Moderate to severe attacks
• Preferred over oral steroids
– Decrease airway hyperresponsiveness
& exacerbations
• Used regularly
 Treatment
• Montelukast-Leukotriene Modifiers
– Less efficacious than inhaled steroids

• Cromolyn sodium/nedocromil sodium

– Only for prophylaxis
– Usually given before exercise
– Rarely used in adults
 Treatment
• Acute Severe Asthma Exacerbation
– Inhaled B2-agonist (first line)
• Nebulizer or Metered Dose Inhaler (MDI)
• Onset within minutes
– Corticosteroids
• IV (initial) / Oral (equivalent doses)
• Taper IV / Oral upon improvement
• Initiate inhaled corticosteroids at beginning of
tapering schedule
 Treatment
• Acute Severe Asthma Exacerbation
– Third-line agents
• Theophylline / Aminophylline
• IV Magnesium Sulfate
– Supplemental O2
• Keep SO2 > 90%
– Antibiotics
– Intubation
 Complications of Asthma
• Status asthmaticus
Does not respond to standard
medications
• Acute respiratory failure
Due to respiratory muscle fatigue
• Pneumothorax, atelectasis, and
pneumomediastinum.
 A 56-Year-Old Woman with a History of
Hodgkin's Lymphoma and Sudden Onset of
Dyspnea and Shock

bilateral upper-lobe
paramediastinal
architectural
distortion
 What is Bronchiectasis
• irreversible dilation
• obstructive lung disease
• Necrotizing bacteria -
staph, klebsiella and
boretella pertussis
-posterior mid lung shows extensive varicose
bronchiectasis
-loss of parenchyma between the crowded airways
 Signs and symptoms
• a green + yellow sputum –
8 oz glass of sputum daily!!!

• bad breath
 DX
• “tree in bud”
formation
• cysts with definable
borders
 Etiology
• AIDS – leading cause of bronchiectasis
• Tuberculosis
• IBD
• rheumatoid arthritis and who smoke

Congenital causes
-Kartagener's syndrome
-Cystic fibrosis
-Alpha 1 antitrypsin deficiency
Treatment + management
 Prevention
• Immunizations – measles, pertussis, pneumonia,
influenza
• Smoking cessation
• Regular check ups
• Hypoxemia, hypercapnia, dyspnea
Questions
 References
• Kaushik VV, Hutchison D, Desmond J, Lynch MP, Dawson JK.
2004 “Association between bronchiactasis and smoking in
patients with rheumatoid arthritis” Annals of the
Rheumatic disease 63:8, 1001-2
• Hassan I 2006 “Bronchiactasis” WebMD
• Lamari NM, Martins ALQ, Oliveria JV, Marino LC, Valerio N
2006. “Bronchiectasis and clearance physiotherapy:
emphasis in postrual drainage and percussion” Brasz. J.
Cardiovasc. Surg 21:2
• Ng AK, Abramson JS, Digumarthy SR, Reingold JS, Stone
“Case 24-2010 — A 56-Year-Old Woman with a History of
Hodgkin's Lymphoma and Sudden Onset of Dyspnea and
Shock” JR, N Engl J Med 2010; 363:664-675