Your SlideShare is downloading. ×
0
Educational aims:
•Not all people who report respiratory symptoms have
asthma.
•COUGH, WHEEZING (AND other respiratory noi...
Hallmarks of asthma
Overview of differential diagnosis
Distinguishing asthma from COPD
Distinguishing asthma from VCD
Dist...
.A chronic inflammatory disorder of the airways
.Many cells and cellular elements play a role
.Chronic inflammation is ass...
The distinguishing characteristic of asthma :
•is the response to bronchodilator or
corticosteroids when the patient is sy...
•symptoms within 5 to 7 days of optimal medication and
•Pulmonary function after a maximum of 10 days
Argues against asthm...
MISDIAGNOSIS OF NON-ASTHMATIC CONDITIONS AS
UNCONTROLLED ASTHMA HAS BEEN REPORTED TO BE AS HIGH
AS 12–30%
So, the evaluation should start with:
• Careful history with emphasis on asthma symptoms
including dyspnoea (and relation ...
•1) Rhinosinusitis/(adults) nasal polyps
•2) Psychological factors: personality trait, symptom
perception, anxiety, depres...
Children
1. Bronchiolitis
2. Recurrent (micro)aspiration, reflux, swallowing
dysfunction
3. Prematurity and related lung d...
9.Carcinoid or other tumour
10.Mediastinal mass/enlarged lymph node
11.Congenital heart disease
12.Interstitial lung disea...
1. Dysfunctional breathlessness/vocal cord
dysfunction(VCD)
2. Chronic obstructive pulmonary disease(COPD)
3. Hyperventila...
9.Hypereosinophilic syndromes
10.Pulmonary embolus
11.Herpetic tracheobronchitis
12.Endobronchial lesion/foreign body (e.g...
• Vocal cord dysfunction (VCD) is the intermittent, abnormal
adduction of the vocal cords during respiration
resulting in ...
• One type occurs spontaneously,
with the patient experiencing dyspnea and inspiratory
stridor (often described as “wheezi...
• FIGURE 5
Flow-volume loops obtained before and when symptomatic for 2 patterns of vocal cord
dysfunction syndrome. A, Pr...
• The gold standard for the diagnosis of VCD is by direct
observation of the vocal cords with videolaryngostroboscopy (VLS...
• intermittent shortness of breath
• wheezing,
• stridor,
• or cough, which may be interpreted as
• worsening asthma contr...
The concept of a hyper-responsive larynx, similar to the
hyper-responsive airway in asthma, has been the focus of
recent s...
VCD ASTHMA
FEV1/FVC
FEV1
Normal
Normal
Low
Low
Flow volume loop Flattening of the inspiratory
limb
affection of the expira...
VCD ASTHMA
Pattern of dyspneic event Sudden onset and
relatively rapid
cessation
More gradual onset , longer
recovery peri...
• Speech therapy
The mainstays of treatment for vocal cord dysfunction (VCD) involve teaching the
patient vocal cord relax...
• Asthma and chronic obstructive pulmonary
disease (COPD) are both characterized by airway obstruction, which is
variable ...
Despite the similarity of some clinical features of asthma and COPD,
• there are marked differences in the pattern of infl...
P.J. Barnes ,
Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD
:Breathe| March 2011| Volume 7| No 3
Clinical criteria ASTHMA COPD
Age of onset any age elderly smokers
Classic
symptoms
Episodic wheezing,
cough, dyspnea and
...
Comparison of Asthma and COPD
criteria ASTHMA COPD
Chest radiology Hyperinflation in acute
attack
Hyperinflation and
hyper...
Comparison of Asthma and COPD
Pathological criteria ASTHMA COPD
inflammatory
cells
Eosinophils
Neutrophils
Mast cells
CD4+...
Comparison of Asthma and COPD
Response to treatment ASTHMA COPD
Response to
Corticosteroids
Response to
bronchodilators
go...
Figure 1 Inflammatory and immune cells involved in
asthma
P.J. Barnes ,
Similarities and differences in Inflamatory Mechan...
Figure 2
Inflammatory and immune cells involved in chronic obstructive
pulmonarydisease (COPD)
P.J. Barnes ,
Similarities ...
Figure 3
Contrasting histopathology of asthma and chronic obstructive pulmonarydisease (COPD).
small airway from a patient...
Although the inflammatory and immune
mechanisms of asthma and COPD described
above are markedly different, there are sever...
Table Comparison between asthma and chronic obstructive pulmonary
disease (COPD) inflammation patterns
The Asthma–Chronic Obstructive
Pulmonary Disease Overlap
Syndrome
• Asthma–chronic obstructive pulmonary disease (COPD) ov...
Cardiac asthma as a common masquerader of asthma
• Congestive heart failure causes engorged pulmonary vessels and
intersti...
• Tracheal and bronchial lesions (central airway obstruction)
A variety of airway tumors are reported to manifest with sym...
• Sinus disease
Sinus disease and post nasal drip , especially in children,
is associated with bronchial asthma and wheezi...
• Other conditions and factors
Other extrinsic conditions, such as
lymphadenopathy from Hodgkin lymphoma of
the upper medi...
Less Common Asthma Masqueraders
Habit-Cough Syndrome
Habit-cough syndrome is common in children
It is a troublesome disord...
Tracheomalacia
• Malacia = “softness”
Normal intrathoracic trachea dilates somewhat with inspiration and narrows with expi...
Causes of tracheomalacia
• Congenital disease: (also called primary): consequence of the inadequate
maturity of tracheobro...
Direct visualization by bronchoscopy is the gold
standard to document a narrowing of at least
50% in the sagittal diameter...
FIGURE
Bronchomalacia of the right upper lobe (A) and the right main stem (B). Depending on
the degree of obstruction caus...
Other Rare Causes of Chronic Cough which masquerades asthma
There are some particularly unusual causes of
chronic cough th...
• Reactive Airways Dysfunction Syndrome or RADS is a term
proposed by Stuart M. Brooks M.D. and colleagues in 198. To
desc...
Often, the term "reactive airway disease" is used
when asthma is suspected, but not yet
confirmed.
Reactive airway disease...
HOME MESSAGE
• Not all people who report respiratory symptoms have asthma
• COUGH, WHEEZING (AND other respiratory noises)...
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Similarities and differences between asthma and asthma masqueraders
Upcoming SlideShare
Loading in...5
×

Similarities and differences between asthma and asthma masqueraders

940

Published on

Asthma Masqueraders

0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
940
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
58
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide
  • www.pediatrics.org/cgi/doi/10.1542/
    peds.2007-0078
  • www.pediatrics.org/cgi/doi/10.1542/
    peds.2007-0078
  • (ERS/ATS GUIDELINES ON SEVERE ASTHMA 2014)
  • ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL.
  • ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL
  • ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL
  • ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL
  • ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL
  • Transcript of "Similarities and differences between asthma and asthma masqueraders"

    1. 1. Educational aims: •Not all people who report respiratory symptoms have asthma. •COUGH, WHEEZING (AND other respiratory noises), and dyspnea are common respiratory symptoms that potentially have an extensive differential diagnosis. •The diagnosis of asthma should be documented by variable lung function, airway hyperresponsiveness and inflammation
    2. 2. Hallmarks of asthma Overview of differential diagnosis Distinguishing asthma from COPD Distinguishing asthma from VCD Distinguishing asthma from cardiac asthma Less common and uncommon masqueraders
    3. 3. .A chronic inflammatory disorder of the airways .Many cells and cellular elements play a role .Chronic inflammation is associated with airway hyper responsiveness that leads to recurrent episodes of • wheezing • breathlessness • chest tightness • and coughing particularly at night or in the early morning • Widespread, variable, and often reversible airflow obstruction
    4. 4. The distinguishing characteristic of asthma : •is the response to bronchodilator or corticosteroids when the patient is symptomatic. •For patients who are old enough to perform a pulmonary function test, substantial improvement of airway obstruction from an aerosol bronchodilator or a short course of reasonably high-dose systemic corticosteroid, 2mg/kg twice daily to a maximum of 40 mg twice daily WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007
    5. 5. •symptoms within 5 to 7 days of optimal medication and •Pulmonary function after a maximum of 10 days Argues against asthma as the etiology, Provided that the patient has taken the medication. WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007
    6. 6. MISDIAGNOSIS OF NON-ASTHMATIC CONDITIONS AS UNCONTROLLED ASTHMA HAS BEEN REPORTED TO BE AS HIGH AS 12–30%
    7. 7. So, the evaluation should start with: • Careful history with emphasis on asthma symptoms including dyspnoea (and relation to exercise), cough, wheezing, chest tightness and nocturnal awakenings. • In addition, information should be obtained on exacerbating triggers, environmental or occupational factors and comorbidities that may be contributing. • Children and adults should be evaluated for other conditions that may mimic or be associated with asthma
    8. 8. •1) Rhinosinusitis/(adults) nasal polyps •2) Psychological factors: personality trait, symptom perception, anxiety, depression •3) Vocal cord dysfunction •4) Obesity •5) Smoking/smoking related disease •6) Obstructive sleep apnoea •7) Hyperventilation syndrome •8) Hormonal influences: premenstrual, menarche, menopause, thyroid disorders •9) Gastro-oesophageal reflux disease (symptomatic) •10) Drugs: aspirin, non-steroidal anti-inflammatory drugs (NSAIDs),b-adrenergic blockers, angiotensinconverting enzyme inhibitors ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL, 2014
    9. 9. Children 1. Bronchiolitis 2. Recurrent (micro)aspiration, reflux, swallowing dysfunction 3. Prematurity and related lung disease 4. Cystic fibrosis 5. Congenital or acquired immune deficiency 6. Primary ciliary dyskinesia 7. Tracheobronchomalacia 8. ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL, 2014
    10. 10. 9.Carcinoid or other tumour 10.Mediastinal mass/enlarged lymph node 11.Congenital heart disease 12.Interstitial lung disease 13.Connective tissue disease 14.Central airways obstruction/compression 15.Foreign body 16.Congenital malformations including vascular ring 17.habit-cough syndrome 18.Exercise-induced supraventricular tachycardia 19.Exercise-induced laryngomalacia ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL, 2014
    11. 11. 1. Dysfunctional breathlessness/vocal cord dysfunction(VCD) 2. Chronic obstructive pulmonary disease(COPD) 3. Hyperventilation with panic attacks 4. Bronchiolitis obliterans 5. Congestive heart failure 6. Adverse drug reaction (e.g. angiotensin- converting enzyme inhibitors) 7. Bronchiectasis/cystic fibrosis 8. Hypersensitivity pneumonitis ERS/ATS GUIDELINES ON SEVERE ASTHMA | K.F. CHUNG ET AL, 2014
    12. 12. 9.Hypereosinophilic syndromes 10.Pulmonary embolus 11.Herpetic tracheobronchitis 12.Endobronchial lesion/foreign body (e.g. amyloid, carcinoid, tracheal stricture) 13.Allergic bronchopulmonary aspergillosis 14.Acquired tracheobronchomalacia 15.Churg–Strauss syndrome 16. Pulmonary migraine(Pulmonary migraine consists of combined recurrent asthma; cough with thick mucoid sputum; lower back pain radiating to the shoulder; subtotal or total atelectasis of a segment or lobe; focal headache, occasionally, nausea with vomiting)due to Spastic narrowing of the bronchi is postulated—along with retained mucous secretions, smooth muscle hypertrophy, and thickened bronchial walls . Cerebral and abdominal vascular migraine episodes are believed to accompany pulmonary migraine.{Tucker GF Jr. Pulmonary migraine. Ann Otol Rhinol Laryngol. Sep-Oct 1977;86(5 Pt 1):671-6} 17.Reactive airways dysfunction syndrome
    13. 13. • Vocal cord dysfunction (VCD) is the intermittent, abnormal adduction of the vocal cords during respiration resulting in variable upper airway obstruction. The variable airway obstruction classically affects the inspiratory phase of respiration but the expiratory phase can be affected as well. • VCD frequently co-exists with asthma and complicates effective care and management when not recognized as a separate entity(refractory asthma). • The cord function is reversed in that the vocal folds Adduct on inspiration versus Abduct • Leads to tightness or spasm in the larynx • Inspiratory wheeze evident
    14. 14. • One type occurs spontaneously, with the patient experiencing dyspnea and inspiratory stridor (often described as “wheezing”) at various and often unpredictable times. Whether this is a panic- or anxiety-induced reaction is speculative. • The other phenotype is a reaction that occurs only with exercise, which is commonly seen in adolescent athletes during competitive aerobic activities. Typically transient and relieved spontaneously with a period of rest,
    15. 15. • FIGURE 5 Flow-volume loops obtained before and when symptomatic for 2 patterns of vocal cord dysfunction syndrome. A, Preexercise flow-volume loop with the midinspiratory and midexpiratory flows approximately equal and the postexercise loop exhibiting the typical flattening of the inspiratory portion of the flow-volume loop in a 15-year-old girl with exercise-induced inspiratory stridor that had been described as “wheezing” by previous Physicians.This indicates reversible upper airway obstruction that was then confirmed by visualizing adduction of the vocal cords on inspiration with flexible laryngoscopy. B, Flow- volume loops from a 15-year-old girl with a history of repeated episodes of sudden-onset severe dyspnea. She had spontaneous onset of severe dyspnea during our initial evaluation with marked compromise of both inspiration and expiration illustrated by the spirometric tracing. Flexible laryngoscopy demonstrated the vocal cords and false vocal cords to be severely adducted, leaving only an2-mm opening for air movement except when talking.
    16. 16. • The gold standard for the diagnosis of VCD is by direct observation of the vocal cords with videolaryngostroboscopy (VLS). The variable nature of VCD can limit the diagnostic value of VLS and other direct observational approaches if symptoms are not present at the time of the study. • Anterior portions of the vocal folds are ADDucted • Only a small area of opening at the Posterior aspect of the vocal folds • Diamond shaped ‘CHINK’ • May be evident on both inhalation and exhalation Benninger et al ,Vocal cord dysfunction and asthma: Current Opinion in Pulmonary Medicine2011(17:45–49)
    17. 17. • intermittent shortness of breath • wheezing, • stridor, • or cough, which may be interpreted as • worsening asthma control given their nonspecific nature and can lead to unnecessary increases in asthma therapy. • Difficulty with inspiratory phase • Throat tightening > bronchial/ chest • Dysphonia during/following an attack • Abrupt onset and resolution • Little or NO response to medical treatment (inhalers, bronchodilators) . Benninger et al ,Vocal cord dysfunction and asthma: Current Opinion in Pulmonary Medicine201117:45–49
    18. 18. The concept of a hyper-responsive larynx, similar to the hyper-responsive airway in asthma, has been the focus of recent studies and may help explain the high prevalence of VCD seen in asthmatics. The larynx is highly innervated with sensory and motor nerve fibers which are: thought to become hyperexcitable by intrinsic or extrinsic stimuli resulting in hyperfunctional glottic movement, cough and other laryngeal sensations Benninger et al ,Vocal cord dysfunction and asthma: Current Opinion in Pulmonary Medicine2011 17:45–49
    19. 19. VCD ASTHMA FEV1/FVC FEV1 Normal Normal Low Low Flow volume loop Flattening of the inspiratory limb affection of the expiratory limb Precipitators (triggers) Exercise, extreme temperatures Exercise, extreme temp. temperatur,.. irritants,, emotional stressors ,allergens, Number of triggers Usually one Usually multiple Breathing obstruction Laryngeal area Chest area location Timing of breathing Stridor on Wheezing on noises inspiration exhalation
    20. 20. VCD ASTHMA Pattern of dyspneic event Sudden onset and relatively rapid cessation More gradual onset , longer recovery period Nocturnal awakening with symptoms Rarely Almost always Response to broncho- dilators and/or systemic corticosteroids No response Good response
    21. 21. • Speech therapy The mainstays of treatment for vocal cord dysfunction (VCD) involve teaching the patient vocal cord relaxation techniques and breathing exercises. These procedures have been very successful and are used concomitantly with psychological support in difficult cases • Psychotherapy • The role of the psychiatrist is to implement cognitive behavior psychotherapy or general psychotherapy based upon evaluation of psychiatric and/or personality disorders. • Helium-oxygen therapy in the emergent treatment of acute VCD. • Anticholinergic agent Inhaled ipratropium may be helpful treatment in patients with exercise- induced VCD Benninger et al ,Vocal cord dysfunction and asthma: Current Opinion in Pulmonary Medicine201117:45–49 Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. Jan 15 2010;81(2):156-9
    22. 22. • Asthma and chronic obstructive pulmonary disease (COPD) are both characterized by airway obstruction, which is variable and reversible in asthma but is progressive and largely irreversible in COPD • In both diseases, -there is chronic inflammation of the respiratory tract, which is mediated by the increased expression of multiple inflammatory proteins, including cytokines, chemokines, adhesion molecules, inflammatory enzymes and receptors • In both diseases there are acute episodes or exacerbations, when the intensity of this inflammation increases. P.J. Barnes , Similarities and differences in Inflammatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    23. 23. Despite the similarity of some clinical features of asthma and COPD, • there are marked differences in the pattern of inflammation that occurs in the respiratory tract • different mediators produced, distinct consequences of inflammation and differing responses to therapy. In addition, the inflammation seen in asthma is mainly located in the larger conducting airways, although small airways may also be involved in more severe disease • P.J. Barnes , • Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    24. 24. P.J. Barnes , Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    25. 25. Clinical criteria ASTHMA COPD Age of onset any age elderly smokers Classic symptoms Episodic wheezing, cough, dyspnea and chest tightness dyspnea on exertion Relation of sx to respiratory Cycle exhalation > inhalation exhalation > inhalation Tilles SA, Nelson HS Current Review of asthma. Current Medicine, 2003
    26. 26. Comparison of Asthma and COPD criteria ASTHMA COPD Chest radiology Hyperinflation in acute attack Hyperinflation and hyperlucency PFTs reversible Obstruction Increased volumes, normal or increased DLCO irreversible obstruction Increased volumes, , decreased DLCO Tilles SA, Nelson HS Current Review of asthma. Current Medicine, 2003
    27. 27. Comparison of Asthma and COPD Pathological criteria ASTHMA COPD inflammatory cells Eosinophils Neutrophils Mast cells CD4+ T cells Th2 Neutrophils Macrophages Th2 ,CD8+ T cells Structural changes Airway sm muscle +++ All airways No Parenchymal change Epithelial shedding Fibrosis + (subepithelial) Mucous secretion + Airway sm muscle + Peripheral airways Parenchymal destruction Epithelial metaplasia Fibrosis ++ (peribronchiolar) Mucous secretion +++ Tzortzaki EG, et al J Allergy 2011; 2011:843543
    28. 28. Comparison of Asthma and COPD Response to treatment ASTHMA COPD Response to Corticosteroids Response to bronchodilators good good modest Poor good modest Tilles SA, Nelson HS Current Review of asthma. Current Medicine, 2003
    29. 29. Figure 1 Inflammatory and immune cells involved in asthma P.J. Barnes , Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    30. 30. Figure 2 Inflammatory and immune cells involved in chronic obstructive pulmonarydisease (COPD) P.J. Barnes , Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    31. 31. Figure 3 Contrasting histopathology of asthma and chronic obstructive pulmonarydisease (COPD). small airway from a patient who died from asthma and a similar sized airway from a patient with severe COPD are shown. There is an infiltration with inflammatory cells in both diseases. The airway smooth muscle (ASM) layer is thickened in asthma but only to a minimal degree in COPD. The basement membrane (BM) is thickened in asthma due to collagen deposition (subepithelial fibrosis) but not in COPD, whereas in COPD collagen is deposited mainly around the airway (peribronchiolar fibrosis). The alveolar attachments are intact in asthma, but disrupted in COPD as a result of emphysema. Images courtesy of J. Hogg (Vancouver, Canada). P.J. Barnes , Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    32. 32. Although the inflammatory and immune mechanisms of asthma and COPD described above are markedly different, there are several situations where they become more similar and the distinction between asthma and COPD becomes blurred as in table P.J. Barnes , Similarities and differences in Inflamatory Mechanisms of Asthma andCOPD :Breathe| March 2011| Volume 7| No 3
    33. 33. Table Comparison between asthma and chronic obstructive pulmonary disease (COPD) inflammation patterns
    34. 34. The Asthma–Chronic Obstructive Pulmonary Disease Overlap Syndrome • Asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is a commonly encountered yet loosely defined clinical entity. ACOS accounts for approximately 15–25% of the obstructive airway diseases and patients experience worse outcomes compared with asthma or COPD alone. Patients with ACOS have the • combined risk factors of smoking and atopy, are generally younger than patients with COPD and experience acute exacerbations with higher frequency and greater severity than lone COPD major criteria for ACOS: 1.A physician diagnosis of asthma and COPD in the same patient, history or evidence of atopy, for example, hay fever, elevated total IgE 2.Age 40 years or more, smoking >10 pack-years, 3.postbronchodilator FEV1 <80% predicted and FEV1/FVC <70%. A ≥15% increase in • FEV1 ≥12% and ≥200 ml increase in FEV1 postbronchodilator treatment with albuterol would be a minor criteria. Louie et al Asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) Expert Rev Clin Pharmacol. 2013;6(2):197-219
    35. 35. Cardiac asthma as a common masquerader of asthma • Congestive heart failure causes engorged pulmonary vessels and interstitial pulmonary edema, which reduce lung compliance and contribute to the sensation of dyspnea and wheezing. Cardiac asthma is characterized by wheezing secondary to bronchospasm in congestive heart failure, and it is related to paroxysmal nocturnal dyspnea and nocturnal coughing Characterstic features: Dysnea on exertion,PND Rales Early night symptoms Gallop rhythm and S3 CXR and Echocardiography are diagnostic Asthma Differential Diagnoses -emedicine.medscape.com/article/296301- differential
    36. 36. • Tracheal and bronchial lesions (central airway obstruction) A variety of airway tumors are reported to manifest with symptoms similar to those of asthma. These tumors include endobronchial carcinoid and mucoepidermoid tumors when causing partial airway obstruction • Foreign bodies Foreign body aspiration may cause not only localized wheezing but also generalized wheezing. Wheezing occurs in toddlers as well as in adults. As described in one patient, foreign body aspiration may necessitate bronchoscopic retrieval before the patient even recalls the inciting event, and as many as 25% of patients may never recall the event. Asthma Differential Diagnoses - emedicine.medscape.com/article/296301- differential
    37. 37. • Sinus disease Sinus disease and post nasal drip , especially in children, is associated with bronchial asthma and wheezing. • Gastroesophageal reflux Cough, recurrent bronchitis, pneumonia, wheezing, and asthma are associated with gastroesophageal reflux (GER).The incidence of GER in patients with asthma ranges from 38% in patients with only asthma symptoms to 48% in patients with recurrent pneumonia Asthma Differential Diagnoses - emedicine.medscape.com/article/296301- differential
    38. 38. • Other conditions and factors Other extrinsic conditions, such as lymphadenopathy from Hodgkin lymphoma of the upper mediastinum, can contribute to asthma. In addition, aspirin or NSAID hypersensitivity and reactive airways dysfunction syndrome may be mistaken for asthma. Misdiagnoses as refractory bronchial asthma has resulted in inappropriate long-term treatment with corticosteroids. Asthma Differential Diagnoses -emedicine.medscape.com/article/296301- differential
    39. 39. Less Common Asthma Masqueraders Habit-Cough Syndrome Habit-cough syndrome is common in children It is a troublesome disorder that commonly is treated as asthma that often results in a great deal of morbidity and ineffective treatment and yet is readily curable rapidly with suggestion therapy with a simple behavioral technique. The classical presentation of habit-cough syndrome 1. is that of a harsh, barking, repetitive cough that occurs several times per minute for hours 2. the complete absence of cough once the patientis asleep. 3. a high incidence of abdominal pain and irritable bowel syndrome in many of the children with habit-cough syndrome, In considering treatment and discussing the issue with the family, it is important not to refer to this as a psychogenic cough WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007
    40. 40. Tracheomalacia • Malacia = “softness” Normal intrathoracic trachea dilates somewhat with inspiration and narrows with expiration • Inadequate rigidity of the tracheal or main-stem bronchial cartilage results in tracheal collapse, which causes cough by at least 2 mechanisms 1. Collapse of the trachea or main-stem bronchi during increased intrathoracic pressure as in vigorous exhalation or coughing can cause the anterior and posterior walls to come into contact, which results in an irritable focus that stimulates further cough. 2.In addition, when secretions are present in the airway, the airway collapse prevents normal airway clearance of secretions. The secretions then act as a continued stimulus for a nonproductive cough. • Types: • Tracheomalacia - trachea • Bronchomalacia - one or both of the main-stem bronchi • Tracheobronchomalacia - both WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007
    41. 41. Causes of tracheomalacia • Congenital disease: (also called primary): consequence of the inadequate maturity of tracheobronchial cartilage – Polychondritis – Chondromalacia – Mucopolysaccharidoses: Hunter syndrome and Hurler syndrome – Idiopathic “giant trachea” or Mounier- Kuhn syndrome – Acquired Tracheomalacia: • Posttraumatic – Post-intubation – Post-tracheostomy • Emphysema • Chronic infection/bronchitis • Chronic inflammation – Relapsing polychondritis • Chronic external compression of the trachea – Malignancy – Benign tumors – Cysts – Abscesses – Aortic aneurysm • Vascular rings, previously undiagnosed in childhood WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007 Less Common Asthma Masqueraders
    42. 42. Direct visualization by bronchoscopy is the gold standard to document a narrowing of at least 50% in the sagittal diameter in expiration – Mild : obstruction during expiration is to one half of the lumen – Moderate : obstruction reaches three quarters of the lumen – Severe : the posterior wall touches the anterior wall Nuutinen J. Acquired tracheobronchomalacia: a clinical study with bronchological correlations. Ann Clin Res 1977;9:350–355
    43. 43. FIGURE Bronchomalacia of the right upper lobe (A) and the right main stem (B). Depending on the degree of obstruction caused by the malacia, either cough or expiratory monophonic wheezing may be heard. Obstruction occurs on expiration with positive intrathoracic pressure during expiration while negative intrathoracic pressure during inspiration opens the airway. Complete airway obstruction during expiration can result in lobar emphysema from persistent hyperinflation of the lobe distal to the malacia. Decreased clearing of secretions distal to the malacia may be associated with purulent bacterial bronchitis.
    44. 44. Other Rare Causes of Chronic Cough which masquerades asthma There are some particularly unusual causes of chronic cough that were misdiagnosed as asthma. Although unlikely to be encountered frequently, awareness of these entities can encourage additional investigation when the pattern of symptoms and response to treatment is not consistent with asthma. A uvula that was in contact with the epiglottis was cause of along standing . FIGURE Tonsils (the lateral masses in the image) impinging on the epiglottis in a 3-year-old girl caused chronic cough that initially was treated unsuccessfully as asthma. A tonsillectomy cured her cough WEINBERGER, ABU-HASAN :Pesudo-asthma: W hen Cough, Wheezing, and Dyspnea Are Not Asthma .PEDIATRICS Volume120, Number 4, October 2007
    45. 45. • Reactive Airways Dysfunction Syndrome or RADS is a term proposed by Stuart M. Brooks M.D. and colleagues in 198. To describe an asthma-like syndrome developing after a single exposure to high levels of an irritating vapor, fume, or smoke. It involves coughing, wheezing, and dysnea. • It can also manifest in adults with exposure to high levels of chlorine, ammonia, acetic acid or sulphur dioxide, creating symptoms like asthma.[6] The severity of these symptoms can be mild to fatal, and can even create long-term airway damage depending on the amount of exposure and the concentration of chlorine. Some experts classify RADS as occupational asthma. Those with exposure to highly irritating substances should receive treatment to mitigate harmful effects Aslan et al 2008 . "The Effect of Nebulized NaHCO3 Treatment on 'RADS' Due to Chlorine Gas Inhalation". Inhalation Toxicology: Vol. 18, Number 11
    46. 46. Often, the term "reactive airway disease" is used when asthma is suspected, but not yet confirmed. Reactive airway disease in children is a general term that doesn't indicate a specific diagnosis. It may be used to describe a history of coughing, wheezing or shortness of breath triggered by infection. These signs and symptoms may or may not be caused by asthma.
    47. 47. HOME MESSAGE • Not all people who report respiratory symptoms have asthma • COUGH, WHEEZING (AND other respiratory noises), and dyspnea are common respiratory symptoms that potentially have an extensive differential diagnosis. • The distinguishing characteristic of asthma : - is the response to bronchodilator orcorticosteroids when the patient is symptomatic -Improvement of airway obstruction from an aerosol bronchodilator or a short course of systemic corticosteroid which is documented by PFTs. Argues against asthma as the etiology, Provided that the patient has taken the medication
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×