1.

Define asthma and describe the pathophysiology of the disease.

MC chronic disease of childhood

airway inflammation mediated mainly by mast cells, eosinophils, TH2 lymphocytes (hygiene hypothesis).

Neutrophilic inflammation is less characteristic but has been described in sudden-onset and fatal asthma exacerbations.

Cytokines and proinflammatory substances released by these cells contribute to hyperresponsiveness of the airway
bronchoconstriction, airway edema, mucus hypersecretion, denudation of the airway epithelium.

Early in its course, the airway obstruction in asthma is almost always fully reversible with treatment, but
undertreatment and poor control can lead to airway remodeling, which can evolve into persistent airway obstruction.

MOA not fully understood

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Atopy: typified by many IgE-mediated immune responses to allergens, is a strong risk factor for developing asthma.
There may be a genetic component to this since atopy may have a familial predisposition.
o
Obesity has also been implicated as a risk factor for the development of asthma.
o
Environmental factors that have been identified as possible factors in the development of asthma include exposure
to allergens, certain infections, inhaled substances at the workplace, and diet in early childhood.

Pulmonary index Score (PIS) is an asthma score based on 5 clinical variables: RR, degree of wheezing,
inspiratory:expiratory ratio, accessory muscle use, and O2 sat. Each variable is assigned a score from 0-3. Total
scores range from 0-15.
o
As a general rule, a score of 7-11 indicates an exacerbation of moderate severity and a score of 12 indicates
a severe attack. However, the PIS may underestimate the degree of illness in an older child; bradypnea,
caused by a prolonged expiratory phase, will result in fewer points for the RR component.
o
The PIS has been validated and used as an outcome measure in several clinical trials. It can be used to
assess initial severity, judge response to treatment, and facilitate admission and discharge planning.
Wheezing

Accessory muscle
use

Score

Respiratory rate*

Inspiratory/ expiratory ratio

Oxygen saturation

30

None

2:1

None

99-100

31-45

End expiration

1:1

96-98

46-60

Entire expiration

1:2

++

93-95

>60

Inspiration and expiration

1:3

+++

<93

2. Recognize the clinical presentation of childhood causes of dyspnea to include:

Asthma

may present with cough, wheezing, or SOB, chest tightness

may be predictably worse during certain seasons, a diurnal variation with symptoms being worse at night or early
morning is characteristic of asthma.

cannot be proven by PE or spirometry: may be normal in the absence of an exacerbation of asthma.

Clues in diagnosis: use of accessory respiratory muscle groups, hyperexpansion of the thorax, prolonged expiratory
time, decreased breath sounds, and wheezing on auscultation, nasal polyps and skin manifestations of atopic dermatitis
or eczema.

Exposures or factors that can worsen asthma symptoms: pollen, chemicals/dust, URTI, animal dander, dust mites, mold,
smoke, changes in weather, extreme emotions, exercise, GERD, postnasal drip, menses, medication allergies, B-blockers
1* ciliary dyskinesia (PCD) / Kartageners

AR, situs inversus, infertility, bronchiectasis or mucus plugs, R/O measuring amount of exhaled nasal nitric oxide
(nNO) expect low or absent if PCD. Sensitivity 97% and specificity 90%. Tests measuring nasal nitric oxide and
mucociliary clearance are useful for screening, but require confirmation with tests of ciliary function and
ultrastructure
Pseudocroup/Croup:

breathing difficulty accompanied by a "barking" cough d/t swelling around the vocal cords, common in infants and
children 3mo-5yo

Viral croup is the most common: parainfluenza virus, but RSV, measles, adenovirus, and influenza can all cause croup

Other possible causes include bacteria, allergies, inhaled irritants. Acid reflux from the stomach can trigger croup.

Northern hemisphere, most common between October-March, but can occur at any time of the year.

In severe cases of croup, there may also be a bacterial super-infection of the upper airway. This condition is called bacterial
tracheitis and requires hospitalization and intravenous antibiotics. If the epiglottis becomes infected, the entire windpipe can
swell shut and be potentially fatal.

Most children have what appears to be a mild cold for several days before the barking cough becomes evident. As the
cough gets more frequent, the child may have labored breathing or inspiratory stridor (a harsh, crowing noise made
during inspiration). Croup is typically much worse at night. It often lasts 5 or 6 nights, but the first night or two are usually
the most severe. Rarely, croup can last for weeks.

Diagnosis is usually based on the parent's description of the symptoms and a physical exam, but occasionally other studies,
such as x-rays, are needed. Physical examination may show chest retractions with breathing. Listening to the chest through a
stethoscope may reveal prolonged inspiration or expiration, wheezing, and decreased breath sounds. An examination
of the throat may reveal a red epiglottis. A neck x-ray may reveal a foreign object or narrowing of the trachea.
Bronchiolitis

constellation of clinical symptoms and signs that includes a viral upper respiratory prodrome followed by increased
respiratory effort and wheezing in children < 2yo

Risk factors: Prematurity (gestational age <37 weeks), Low birth weight, Chronic pulmonary disease (bronchopulmonary
dysplasia, CF, congenital anomaly), Hemodynamically significant congenital heart disease (eg, moderate to severe pulmonary

HTN, cyanotic heart disease, or congenital heart disease that requires medication to control heart failure), Immunodeficiency,
Neurologic disease, Congenital or anatomical defects of the airways

Environmental risk factors: older siblings, Concurrent birth siblings, Native American, Passive smoke, Household crowding, Child
care, High altitude

PE: tachypnea and intercostal and subcostal retractions often with expiratory wheezing. The chest may appear
hyperexpanded with increased antero-posterior (AP) diameter and may be hyperresonant to percussion. Findings on
auscultation include any combination of expiratory wheeze, prolonged expiratory phase, and both coarse and fine
crackles. Mild hypoxemia (oxygen saturation <95 percent) commonly is detected by pulse oximetry, even without clinical
signs of desaturation.

Severely affected patients have increased work of breathing with subcostal, intercostal, and supraclavicular retractions,
nasal flaring, and expiratory grunting. They may appear cyanotic and have poor peripheral perfusion. Wheezing may not be
audible if the airways are profoundly narrowed.
Epiglottitis

typically affects children, associated with fever, difficulty in swallowing, drooling, hoarseness of voice, and stridor,
appears acutely ill, anxious, very quiet shallow breathing with the head held forward, insisting on sitting up in bed.
The early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and
asphyxiation.

since the introduction of the Hemophilus infuenzae vaccination in many Western countries (including the UK), the disease
is becoming relatively more common in adults.
Anaphylaxis:

Symptoms related to the action of Immunoglobulin E (IgE) and other anaphylatoxins, which act to release histamine and other
mediator substances from mast cells (degranulation). In addition to other effects, histamine induces vasodilation of arterioles
and constriction of bronchioles in the lungs, also known as bronchospasm (constriction of the airways).

Tissues in different parts of the body release histamine and other substances. This causes constriction of the airways,
resulting in wheezing, difficulty breathing, and gastrointestinal symptoms such as abdominal pain, cramps, v/d.
Histamine causes the blood vessels to dilate (which lowers blood pressure) and fluid to leak from the bloodstream into the
tissues (which lowers the blood volume). These effects result in shock. Fluid can leak into the alveoli (air sacs) of the lungs,
causing pulmonary edema.

Symptoms can include: respiratory distress, hTN, syncope, urticaria, flushed appearance, angioedema, tears, itching, anxiety
3. Describe the abnormal breath sounds: crackles, rubs, wheezing, rhonchi
crackles or crepitations (~Rice Krispies)

Inspiratory popping noises heard on auscultation of the lungs

discontinuous, nonmusical and brief.

pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis, bronchiectasis or pulmonary edema secondary to LCHF, ARDS.
Rub

dry, scraping or grating sound heard during auscultation. The sound is caused by the rubbing together or two serous
surfaces. It is a normal finding when heard over the liver and splenic areas. A friction rub auscultated over the pericardial area
(pericardial rub) is suggestive of pericarditis; a rub over the pleural area (pleuritic rub) is caused by friction between visceral
and costal pleurae and may be a sign of lung disease.
Wheeze

continuous musical sound heard during chest auscultation that lasts longer than 250 msec .
requires sufficient airflow to generate oscillation of opposing walls of an airway narrowed almost to the point of
closurebeware of impending respiratory failure in pt with acute asthmatic attack if NO wheezing heard!

high-pitched or low-pitched, consist of single or multiple notes, and occur during inspiration or expiration

Common causes of wheezing are Asthma attacks (most common cause), Bronchiolitis, COPD, Medication-induced
bronchoconstriction, Pulmonary edema, Tracheobronchitis, Vocal cord dysfunction, and Anaphylaxis.

Bronchiolar disease usually causes wheezing that occurs in the expiratory phase of respiration.

inspiratory phase on the other hand is often a sign of a stiff stenosis, usually caused by tumors, foreign bodies or
scarring, hypersensitivity pneumonitis.

Wheezes heard at the end of both expiratory and inspiratory phases usually signify the periodic opening of deflated
alveoli, as occurs in some diseases that lead to collapse of parts of the lungs.
Rhonchi

coarse expiratory rattling sound somewhat like snoring, d/t airway is partially obstructed owing to secretions,
mucosal swelling, or tumor tissue pressing on the passage

COPD and acute or severe bronchitis

4. Discuss the methods used to diagnose asthma and distinguish it from chronic airway disease.
In patients who refer classic symptoms of asthma (wheezing, dyspnea) triggered by typical allergens that readily and
completely resolve with the administration of asthmatic treatment, a clinical diagnosis of asthma may be made.
Chest Radiograph should be obtained in every child presenting with wheezing!

not necessary to make a diagnosis of asthma and it is almost always normal. However, it may be helpful in
excluding other diseases that can present similarly (e.g., CHF) as well as recognize comorbid conditions. The chest
radiograph during an acute exacerbation may reveal hyperinflation and subsegmental atelectasis from mucous
plugging. In the presence of fever, chest pain, and wheezing, a CXR may be warranted to exclude the presence of
pneumonia.
Pulmonary Function Tests

peak expiratory flow rates (PEFR) and spirometry. A decreased PEFR has a low specificity and can be seen with other
pulmonary processes. Peak flow measurements are dependent on patient effort and may be reduced in both obstructive and
restrictive diseases, hence reducing their diagnostic utility. Monitoring diurnal variation is mostly helpful in monitoring
disease activity.

The clinical suspicion of asthma should be confirmed with spirometry in patients who are able to perform this.
Performance of the test maneuver may not be satisfactory in children under 7 years old but can be considered for patients

over 4 years of age. Spirometry done before and after an inhaled short-acting B2-agonist (albuterol)
bronchodilator can help confirm whether a patient has airways obstruction and determine whether there is
significant improvement in pulmonary function after an inhaled bronchodilator is given (a significant bronchodilator
response).
The criterion standard for the diagnosis of airway obstruction is a decrease in the ratio of the forced expiratory
volume in 1 second (FEV1) to forced vital capacity (FVC) below that predicted for the subject. Importantly, a FEV1/FVC
that normalizes after the administration of an inhaled bronchodilator demonstrating reversible airway
obstruction supports the diagnosis of asthma.
If the baseline and postbronchodilator spirometry do not demonstrate airway obstruction, a methacholine challenge test
may be indicated to confirm asthma (done quite rarely because it is dangerous). Bronchoprovocation with inhaled
methacholine should trigger a reduction in FEV1 of at least 20%. Spirometric findings of airway obstruction that
significantly improve to normal or near normal values after a bronchodilator should be correlated with clinical features to
make a more accurate diagnosis of asthma.
For suspected exercise-induced asthma, spirometry can be taken before and after a supervised exercise activity.

5) Explain how the treatment of a single attack of asthma varies from treatment of recurrent asthmatic symptoms
Treatment for asthma generally involves avoiding the things that trigger your asthma attacks and taking one or more asthma
medications. Treatment varies from person to person.

If your asthma symptoms are triggered by airborne allergens, such as pollen or pet dander, you may also need allergy
treatment.

You may need to try a few different medications before you find what works best.

Because asthma changes over time, you will need to work with your doctor to monitor your symptoms and learn how to
make needed adjustments.
Long-term control medications

combination of long-term control medications and quick-relief medications, taken with a hand-held inhaler, most likely everyday

Inhaled corticosteroids: fluticasone (Flovent Diskus), budesonide (Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid),
beclomethasone (Qvar) and others. reduce airway inflammation. Unlike oral corticosteroids, these medications are considered
relatively low risk for long-term corticosteroid side effects. You may need to use these medications for several days to
weeks before they reach their maximum benefit.

Long-acting beta-2 agonists (LABAs) such as salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer). open the
airways and reduce inflammation. They are often used to treat persistent asthma in combination with inhaled
corticosteroids. should not be used for quick relief of asthma symptoms.

Leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo CR). These inhaled
medications work by opening airways, reducing inflammation and decreasing mucus production.

Cromolyn and nedocromil (Tilade). Inhaled, reduce asthma signs and symptoms by decreasing allergic reactions.
second choice to inhaled corticosteroids, and need to be taken three or four times a day.

Theophylline, a daily pill that opens your airways (bronchodilator). It relaxes the muscles around the airways.
Quick-relief medications rescue medications

use as needed for rapid, short-term relief of symptoms during an asthma attack, or before exercise, if your doctor
recommends it. If you need to use these medications too often, you probably need to adjust your long-term control medication.
Keep a record of how many puffs you use each day. Types of quick-relief medications include:

Short-acting beta-2 agonists (SABA), such as albuterol, inhaled bronchodilators, ease breathing by temporarily relaxing
airway muscles. They act within minutes, and effects last four to six hours.
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FDA has required that metered-dose albuterol inhalers that use chlorofluorocarbon (CFC) propellent be replaced
with hydrofluoroalkane (HFA) inhalers by the end of 2008. HFA inhalers work as well as CFC inhalers and are as
safe, but they don't harm the ozone layer. HFA inhalers should be cleaned with water every week

Ipratropium (Atrovent). inhaled anticholinergic for the immediate relief of your symptoms. Like other bronchodilators,
ipratropium relaxes the airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic
bronchitis.

Oral and intravenous corticosteroids to treat acute asthma attacks or very severe asthma. Examples include prednisone
and methylprednisolone. These medications relieve airway inflammation. They may cause serious side effects when used long
term, so they're only used to treat severe asthma symptoms.
Medications for allergy-induced asthma.

decrease your body's sensitivity to a particular allergen or prevent your immune system from reacting to allergens.

Immunotherapy. Allergy-desensitization shots generally given 1/wk for a few months, then 1/mo for a period of 35yrs. Over time, they gradually reduce your immune system reaction to specific allergens.

Anti-IgE monoclonal antibodies, such as omalizumab (Xolair). reduces your immune system's reaction to allergens. IV every
2-4wk.
6. describe the role of patient education and allergy evaluation in the treatment of asthma

Develop a written asthma plan. With your doctor and health care team, write a detailed plan for taking maintenance medications
and managing an acute attack.
Identify and avoid asthma triggers.
Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or
shortness of breath. But because your lung function may decrease before you notice any signs or symptoms, regularly measure
your peak airflow with a home peak flow meter.
Identify and treat attacks early. When your peak flow measurements decrease and alert you to an impending attack, take your
medication as instructed and immediately stop any activity that may have triggered the attack. If your symptoms don't improve, get
medical help as directed in your action plan.

Don't let up on your medication program. Just because your asthma seems to be improving, don't change anything
without first talking to your doctor. It's a good idea to bring your medications with you to each doctor visit, so your
doctor can double-check that you're using your medications correctly and taking the right dose.
Avoid your triggers:
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Use your air conditioner. Air conditioning helps reduce the amount of airborne pollen from trees, grasses and weeds that
finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your exposure to dust mites. If you don't
have air conditioning, try to keep your windows closed during pollen season.
o
Decontaminate your decor. Minimize dust that may aggravate nighttime symptoms by replacing certain items in your
bedroom. For example, encase pillows, mattresses and box springs in dust-proof covers. Remove carpeting and install
hardwood or linoleum flooring. Use washable curtains and blinds.
o
Maintain optimal humidity. Keep humidity low in your home and office. If you live in a damp climate, talk to your
doctor about using a dehumidifier.
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Keep indoor air clean. Have a utility company check your air conditioner and furnace once a year. Change the filters in
your furnace and air conditioner according to the manufacturer's instructions. Also consider installing a small-particle
filter in your ventilation system. If you use a humidifier, change the water daily.
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Reduce pet dander. If you're allergic to dander, avoid pets with fur or feathers. Having pets regularly bathed or
groomed also may reduce the amount of dander in your surroundings.
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Clean regularly. Clean your home at least once a week. If you're likely to stir up dust, wear a mask or have someone else
do the cleaning.
Stay healthy: optimal weight, exercise

7. list features of respiratory failure in asthma refer to #3

8. compare the characteristic flow volume loops for a normal patient and patients w/ obstructive and restrictive lung
disease refer to Firstaid graphs