ASTHMA

Definition:
• Chronic inflammatory disease of the airways.
• A condition in which your airways narrow and swell
and may produce extra mucus.

Signs and Symptoms:

• Wheezing
• Cough
• Shortness of breath
• Chest tightness
• Allergies
• Sleep problems resulting from shortness of breath
 For some people, asthma signs and symptoms flare up in certain situations:
◦ Exercise-induced asthma, which may be worse when the air is cold and dry
◦ Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust
◦ Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores, cockroach
waste, or particles of skin and dried saliva shed by pets (pet dander)

Pathophysiology:
◦ Asthma is associated with T helper cell type-2 (Th2) immune responses, which are typical of other atopic
conditions.
◦ Elevated levels of Th2 cells in the airways release specific cytokines, including interleukin-4, IL-5, IL-9
and IL-13, that promote eosinophilic inflammation and immunoglobulin E (IgE) production by mast
cells.
◦ IgE production, triggers the release of inflammatory mediators, such as histamine and cysteinyl
leukotrienes, that cause bronchospasm, edema and increased mucous secretion, which lead to the
characteristic symptoms of asthma.
◦ The mediators and cytokines released during the early phase, trigger a further inflammatory response that
leads to further airway inflammation and bronchial hyperreactivity.
◦ A number of chromosomal regions associated with asthma susceptibility have been identified, such as
those related to the production of IgE antibodies, expression of airway hyperresponsiveness, and the
production of inflammatory mediators.
◦ However, further study is required to determine specific genes involved in asthma as well as the gene-
environment interactions that may lead to expression of the disease.

Types:
There are two types of asthma:
1. Extrinsic or Atopic asthma.
2. Intrinsic or Non-atopic asthma
 Extrinsic or Atopic asthma:
◦ This is the most common type of asthma.
◦ Its onset is usually in the first twenty years of life.
◦ Extrinsic asthma is initiated by type 1 hypersensitivity reaction induced by exposure to an extrinsic
antigen.
◦ It occurs in an atopic region i.e. Who forms IgE antibodies to common materials present in an
environment e.g. pollen, House dust, feathers and ingested allergens derived from fish, egg, milk and
wheat.
◦ Atopy runs in families.
◦ Other allergic disorders such as allergic rhinitis and eczema are often present.
◦ Serum IgE level in increased and skin test against offending agents are positive.
Intrinsic or Non-Atopic asthma:
◦ It occurs mostly in Adults.
◦ External allergens play no part in the production of this type of asthma.
◦ Type 1 hypersensitivity reaction is not involved.
◦ In this type of asthma, a number of stimuli that have little or no effect in normal subject, can trigger
broncospasm such as pulmonary viral infection, aspirin, psychological stress and exercise.
◦ Serum IgE level is normal and skin tests are negative.
Diagnosis:
◦ Medical history
◦ Physical examination
◦ Objective assessment of lung funtion
◦ Bronchoprovocation challenge testing
◦ Assessing for markers of airway inflammation

Medical History:
◦ The diagnosis of asthma should be suspected in patients with recurrent cough, wheeze, chest tightness
and short-ness of breath.
◦ Alternative causes of suspected asthma symptoms should be excluded, such as chronic obstructive
pulmonary disease (COPD), bron-chitis, chronic sinusitis, gastroesophageal reflux disease, recurrent
respiratory infections, and heart disease.
Physical Examination:
• Physical findings are usually only evident if patient is symptomatic
• The most common abnormal physical finding is wheezing, which confirms the presence of airflow limitation
• Physicians should also examine the upper respiratory tract and skin for signs of concurrent Atropic condition
such as allergic rhinitis or dermatitis.
Objective Measurements of Lung Function:
• Spirometry is the preferred objective measure to assess for reversible airway obstruction and to confirm a
diagnosis of asthma.
• It is recommended for all patients over 6 years of age who are able to undergo lung function testing.
• Spirometry must be performed according to proper protocols.
• During spirometry, the patient is instructed to take the deepest breath possible and then to exhale as hard and as
fully as possible into the mouthpiece of the spirometer.
Challenge Testing:
◦ Challenge testing should be conducted in accordance with strict protocols in a laboratory or other facility
equipped to manage acute bronchospasms.
◦ Testing involves the patient inhaling increasing doses or concentrations of a stimulus until a given level
of bronchoconstriction is achieved, typically a 20% fall in FEV-1.
◦ An inhaled rapid-acting bronchodilator is then provided to reverse the obstruction.
◦ Test results are usually expressed as the dose or concentration of the provoking agent that causes the
FEV-1 to drop by 20%.

Non-invasive markers of airway inflammation:

◦ The measurement of inflammatory markers such as sputum eosinophilia or levels of exhaled nitric oxide
can also be useful for diagnosing asthma.
◦ Evidence suggests that exhaled nitric oxide levels may be better able to identify asthmatic patients than
basic lung function testing, and may also be useful for monitoring patient response to asthma therapy.
Allergy skin testing
◦ Allergy skin testing is also recommended to determine the allergic status of the patient and to identify
possible asthma triggers.
◦ Testing is typically performed using the allergens relevant to the patient’s geographic region.
◦ Although allergen-specific IgE tests that provide a measure of a patient’s specific IgE levels against
particular allergens have been suggested as an alternative to skin tests, these tests are less sensitive and
more expensive than skin tests.

Complications:
1. Exhausting, Dehydration.
2. Airway Infections.
3. Pneumothorax.
4. Cor pulmonale.
5. Respiratory failure.
Treatment:
◦ Acute:
✓ B2 agonise: Albuterol (short acting), salmeterol (long acting)
✓Bronchodilation
• Chronic:
✓Corticosteroids: Fluticasone
✓Inhibit multiple inflammatory cytokines .