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Asthma

1. General characteristics
a. Asthma is characterized by three components: obstruction of airflow, bronchial
hyperreactivity, and inflammation of the airway. It is a disease of chronic inflammation
leading to airway narrowing and increased mucus production.
b. Asthma affects 5% of the population. Prevalence, hospitalization, and mortality have
risen during the past 20 years.
c. Many asthma syndromes have been identified: extrinsic allergic, allergic
bronchopulmonary aspergillosis, intrinsic asthma, extrinsic nonallergic, aspirin sensitivity,
exercise induced, and asthma associated with chronic obstructive pulmonary disease
(COPD).
d. The strongest predisposing factor to asthma is atopy. The atopic triad consists of
wheeze, eczema, and seasonal rhinitis.
e. Exacerbations often are correlated with common precipitants: allergens (especially dust
and dust mites, dander, cockroaches, and pollen), exercise, upper respiratory tract
infections, postnasal drip, gastroesophageal reflux disease, drugs (-blockers,
angiotensin-converting enzyme inhibitors, aspirin, nonsteroidal anti-inflammatory drugs
[NSAIDs]), stress, cold air or change in the weather, environmental irritants, and others.
2. Clinical features
a. Patients have an intermittent occurrence of cough, chest tightness, breathlessness, and
wheezing. One-third of
children have no wheeze.
b. Patients undergo asymptomatic periods between these attacks.
c. Asthma is classified according to the frequency of symptoms and pulmonary function
testing. In children, especially those under the age of 5, the classification of asthma
severity is more aggressive (Table 2-6).

3. Laboratory findings
a. Airflow obstruction is indicated by decreased ratio of forced expiratory volume in 1
second to forced vital capacity (FEV1/FVC: 75%). A greater than 10% increase in FEV1
after bronchodilator therapy is supportive of the diagnosis.
b. Arterial blood gas (ABG) measurements may be normal in mild cases, but in severe
cases, they can reveal hypoxemia and hypercapnia, with a PaO2 of less than 60 mm Hg
and a PaCO2 of more than 40 mm Hg. ABGs are rarely indicated or obtained unless the
patient is severely ill or nonresponsive to treatment.
c. CXR may show hyperinflation. Radiography is only indicated if pneumonia is suspected,
the asthma is complicated, or another disorder is suspected.
d. Handheld peak expiratory flow meters estimate variability and quantify severity of
attacks. Use of this objective device should be encouraged in patients with chronic
disease.
e. A histamine or methacholine challenge test (bronchial provocation test) may help to
establish the diagnosis of asthma when spirometry is nondiagnostic. An FEV1 decrease of
more than 20% is diagnostic.

4. Treatment
a. The goals of treatment are to minimize chronic symptoms; prevent recurrent
exacerbations and, thus, minimize the need for urgent care visits; and maintain nearnormal pulmonary function.
b. Asthma medications can be divided into long-term control (corticosteroids, cromolyn,
nedocromil, long-acting bronchodilators, leukotriene modifiers, and theophylline) and
quick-relief medications (short-acting inhaled 2-agonists, ipratropium bromide, and
systemic corticosteroids).
c. Treatment algorithms are based on both the severity of the patients baseline asthma
and the severity of asthma exacerbations. In children, especially those under the age of 5,
the stepwise approach to treatment is more aggressive (Fig. 2-1).
d. -adrenergic agonists should be available to induce bronchodilation during acute
symptoms (rescue medication).
e. Inhaled corticosteroids are the most effective anti-inflammatory medications for
management of chronic asthma.
f. Patients should be educated about their disease and the use of peak flow monitoring.
Daily evaluation of pulmonary function with a peak flow meter is an important component
of optimal asthma management. This type of monitoring warns of changes in disease
status and allows for adjustments on a daily basis if needed. Changes in peak flow will
occur prior to clinical symptoms.