Asthma 2

Bronchial Asthma

Dr. Rafea RasheedPGY1

Objectives

I. Diagnosis

II.Severity of Asthma

III.Complication of Asthma

Diagnosis

History Physical Examination Investigation

History • Respiratory symptoms : occure with triggers

(eg, allergen, exercise, viral infection) and resolve with trigger avoidance.

Three classic symptomsWheeze (high-pitched whistling sound, usually

upon exhalation) Cough (often worse at night) Shortness of breath / difficulty breathing

• Precipitating and/or aggravating factors

Viral respiratory infections

Environmental allergens, indoor (e.g., mold, house-dust,mite, animal dander ) and outdoor

(e.g., pollen)

Characteristics of home including age, location, cooling and heating system, wood-burning

stove, humidifier, carpeting over concrete, presence of molds ,presense of pets with fur or

hair.

Characteristics of rooms :(e.g., bedroom and living room with attention to bedding, floor

covering, stuffed furniture)

Smoking (patient and others in home or daycare)

Exercise

occupational chemicals and dust..

Environmental change (e.g., moving to new home; going on Vacation; workplace.

Irritants (e.g., tobacco smoke, strong odors, air pollutants.

Emotions (e.g., fear, anger, frustration, hard crying or laughing) Stress (e.g., fear, anger, frustration)

Drugs (e.g., aspirin; and other nonsteroidal anti-inflammatory drugs, beta-blockers including eye drops, others)

Food, food additives, and preservatives (e.g., sulfites) Changes in weather, exposure to cold air Endocrine factors (e.g., menses, pregnancy, thyroid disease) comorbid conditions (e.g. sinusitis, rhinitis,

gastroesophageal reflux disease (GERD )

Family history History of asthma, allergy, sinusitis, rhinitis,

eczema, or nasal polyps in close relatives

Social history Daycare, workplace, and school characteristics

that may interfere with adherence Social factors that interfere with adherence,

such as substance abuse Social support/social networks Level of

education completed Employment

Impact of asthma on patient and family Episodes of unscheduled care (emergency department

(ED), urgent care, hospitalization) Number of days missed from school/work Limitation of activity, especially sports and strenuous

work. History of nocturnal awakening Effect on growth, development, behavior, school or work

performance, and lifestyle. Impact on family routines, activities. Economic impact.

Assessment of patient’s and family’s perceptions of disease Family knowledge of asthma and belief in the chronicity of

asthma and in the efficacy of treatment Patient’s perception and beliefs regarding use and long-

term effects of medications Ability of patient and parents, spouse, or partner to cope

with disease Level of family support and patient’s and parents’, spouse’s, or partner’s capacity to recognize severity of an exacerbation Economic resources Sociocultural beliefs

Physical ExaminationThe examination focuses on: upper respiratory tract (increased nasal secretion, mucosal

swelling, and/or nasal polyp) Sign of atopy/allergic rhinitis: conjunctival congestion, occular

shiners, transeverse crease on nose due to constant rubbing chest(sounds of wheezing during normal breathing or

prolonged phase of forced exhalation, hyperexpansion of the thorax, use of accessory muscles, appearance of hunched shoulders, chest deformity)

skin (atopic dermatitis, eczema). Manfistaion of an acute episode of Asthma can be mild,

moderately sever, sever.

Mild episodesRR is increasedaccessory muscles of respiration are not used HR is <100 bpmpulsus paradoxus (an exaggerated fall in

systolic blood pressure during inspiration) is not present.

Auscultation of the chest reveals moderate wheezing, which is often end expiratory.

Spo2> 95%.

Moderately severe episodes RR is increased. accessory muscles of respiration are used. In children, also look for supraclavicular and intercostal

retractions and nasal flaring, as well as abdominal breathing. HR is 100-120 bpm. Loud expiratory wheezing can be heard. pulsus paradoxus may be present (10-20 mm Hg). SPo2 is 91-95%. breathless while talking Infants feeding difficulties and a softer, shorter cry. severe cases, the patient assumes a sitting position.

Severe episodes breathless during rest sit upright talk in words rather than sentences agitated. RR > 30 p/m Accessory muscles are usually used suprasternal retractions are commonly present HR is >120 bpm Loud biphasic (expiratory and inspiratory) wheezing can be

heard, and pulsus paradoxus is often present (20-40 mm Hg) SPO2 < 91%. tripod position

Objective measures:

• Lung Function Test: Spirometry• Lung function is expressed as FEV1/FVC• Person with normal lung funtion can exhale

75% of the total capacity in 1 second.• Any value <75% indicates decreased lung

function

Spirometry

maximal inhalation is followed by a rapid and forceful complete exhalation.

includes measurement of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) .

baseline spirometry obtained in all patients with a suspected diagnosis of asthma.

The results of spirometry can be used to determine the following:– Determine whether baseline airflow limitation

(obstruction) is present (reduced FEV1/FVC ratio)– Assess the reversibility of the obstructive abnormality if the

testing is repeated after administration of a bronchodilator– Characterize the severity of airflow limitation

Serial measurements of lung function over time

Bronchodilator response Should be done in all adult and adolescent patients with

airflow limitation on their baseline spirometry.

Acute reversibility of airflow obstruction is tested by administering 2 to 4 puffs of a quick-acting bronchodilator (eg, albuterol), preferably with a chamber device, and repeating spirometry 10 to 15 minutes later. An increase in FEV1 of 12 %or more, can be attributed to

bronchodilator responsiveness with 95 percent certainty.

The presence of a bronchodilator response, in isolation, is NOT sufficient to make the diagnosis of asthma.

Peak expiratory flow 

PEF is measured during a brief, forceful exhalation, using a simple and inexpensive device (approximately $35).

Usually use to monitor patients with a

known diagnosis of asthma or to assess the role of a particular occupational exposure or trigger, rather than as a tool for the primary diagnosis of asthma.

Technique

can be performed sitting or standing. Proper technique involves taking a maximally

large breath in, putting the peak flow meter quickly to the mouth, sealing the lips around the mouthpiece, and blowing out as hard and fast as possible into the meter.

between 1-2 sec three times and the highest of the three

measurements is recorded.

Exhaled nitric oxide 

The measurement of nitric oxide in a patient's exhaled breath (eNO) but is not widely available.

The test is based on the observation that the eosinophilic airway inflammation associated with asthma leads to up-regulation of nitric oxide synthase in the respiratory mucosa, which in turn generates increased amounts of nitric oxide in the exhaled breath.

Further studies are required to assess the validity of exhaled nitric oxide as a diagnostic test for asthma, particularly among persons with other, potentially confounding respiratory diseases.

Bronchial challenge test (AHR) Demonstrates airway hyper-reactivity due to

bronchoconstriction -↑ concentrations of histamine/ methacholine causes a ↓ in FEV1 if asthmatic. Note: Has a high –ve predictive value but +ve results may be seen in other conditions e.g COPD, CF.

Exercise test For patients whose symptoms are related to exercise If asthmatic exercise should cause ↓ PEF/ FEV1. Diagnostic: FEV1 ≥ 15% ↓ after 6 mins of exercise.

Radiological Generally unhelpful but may show alternative

diagnosis. Acute asthma signs: Hyperinflation and ± lobar

collapse.

Measurement of allergic status Skin-prick tests: Measurement of IgE to confirm

sensitivity to specific agent. Atopic asthma: ↑ sputum or peripheral blood

eosinophil count and ↑ serum total IgE.

Pulse oximetry May show ↓ SaO2 level.

Limitations with Lung Function Tests

Normal values may differ between patients: Gender, age, sex, height

All (FEV,FEV1,FVC,PEFR) cannot detect early lung function deterioration due to bronchspasm and mucus plugging in the small airways.

Confirming diagnosis of Asthma

By responding to bronchodilators PEFR measured before and after

administration of bronchodilatorImprovement of the PEFR by >= 15% could be

confirmation of diagnosisNo improvement doesn't not exclude AsthmaThe test is repeated at several times pre-and-

post bronchodilator to confirm or exclude

Diurnal variation in PEF of more than 20% suggests a diagnosis of Asthma

The presence of allergies or allergic rhinitis in symptomatic patients also suggest diagnosis of Asthma

Confirming diagnosis of Asthma

Complications of asthma include:

AtelectasisBronchitis Pneumothorax Pneumonia Respiratory failure

Impact of Quality of Life

The presence of asthma accounted for 3.18% of people reporting poor life satisfaction

12% of people reporting poor health status 5.90% (reporting high psychological distress,3.58% reporting any reduced activity days. The proportions of people with these adverse

health states attributable to asthma were higher than the proportions attributable to diabetes but lower than the proportions attributable to arthritis.

Thank you