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  1. 1. Asthma and Reactive Airway Disease
  2. 2. Asthma and Reactive Airway Disease Definition of asthma : Inflammatory disorder of small airways characterized by periodic attacks of wheezing, shortness of breath, chest tightness, coughing and improvement with bronchodilator Reactive airway disease : A nonspecific term in clinical contexts ranging from asthma to wheezy bronchitis (especially in children < 3 yrs) to viral bronchiolitis or even to pneumonia and COPD
  3. 3. Pathophysiology of Asthma Environmental stimuli Allergen-Antibody reaction Release of mediators from mast cell, etc Airway inflammation Smooth muscle Edema Increase mucous production contraction
  4. 4. Pathophysiology of asthma
  5. 5. Epidemiology <ul><li>Incidence: 7-10 % of children, 3-5 % of adult </li></ul><ul><li>Half of them develop asthma before age 10, </li></ul><ul><li>most before age 30 </li></ul><ul><li>Worldwide prevalence is increasing </li></ul>
  6. 6. Causes and trigger factors <ul><li>F.Hx. : Risk of developing asthma 7 % if neither parent </li></ul><ul><li>has asthma, 20 % if one parent has asthma, </li></ul><ul><li>and 64 % if both parents have asthma </li></ul><ul><li>Allergen: Pet dander, dust mites, cockroach, </li></ul><ul><li> molds ,pollen </li></ul><ul><li>Respiratory infection: virus (RSV), mycoplasma </li></ul><ul><li>Exercise, stress, cold air, food </li></ul><ul><li>Pollutants: tabacco smoke </li></ul><ul><li>Drugs: ASA, N-SAID, B-blocker, estrogen </li></ul><ul><li>Homonal change: pregnancy, menstruation </li></ul><ul><li>Occupation: chemical, latex, animal protein, flour </li></ul>
  7. 7. Differental Dx. <ul><li>Pediatrics </li></ul><ul><ul><ul><ul><li>Anaphylaxis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Croup or lanyngotracheobronchitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>FB ingestion and aspiration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gastroesophageal reflux disease (GERD) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Congenital HD: VSD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mediastinal mass </li></ul></ul></ul></ul><ul><li>Adult </li></ul><ul><ul><ul><ul><li>COPD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anaphylaxis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GERD/Hiatal hernia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pneumonia /bronchiectasis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tumor </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CHF </li></ul></ul></ul></ul>
  8. 8. Difference between Asthma and COPD <ul><li>Smoking history </li></ul><ul><li>Symptom </li></ul><ul><li>Test result: allergen test, therapeutic test </li></ul>
  9. 9. Differentiating features between Asthma and COPD Features suggesting asthma Features suggesting COPD *Young age of onset *Long history of smoking *Presence of atopy and/or allergie *Usually non-atopic rhinitis *Diurnal day to day, seasonal *Insidious onset of symptoms variation in symptoms and persistent dyspnea *Normal PE, near normal *Slow progression of symptoms spirometry while in a stable state *Marked improvement after *Hyper inflation and abnormal bronchodilators and/or spirometry corticosteroid *Progressive deterioration of lung function over time *12% and 200ml improvement in *Poor response to FEV1, or 15% improvement in bronchodilator and/or PEFR corticosteroid
  10. 10. Laboratory Investigation and Diagnostic test Peripheral blood Radiology -CBC: Eosinophil -CXR, sinus -Total Ig E and specific Ig E to allergens -CT scan -ESR Lung function -Spirometry: pre and post bronchodilator -Arterial blood gas -Histamine challenge test Additional test -Antinutrophil cytoplasmic antibodies -Ig G against asprgillus fumigatus -ECG -Nasal endoscope -24 h esophageal PH monitoring -Polysomnography -Bronchoscope -Ventilation/perfusion scan of the thorax
  11. 11. Spirometer Spirogram
  12. 12. Pulmonary Function test Equipment : Spirometer  Spirograph and spirogram Variable : Age, gender, height and size, race Terminology : FVC= Forced vital capacity (liters) FEV1= Forced expiratory volume in one second (liters) FEV1/FVC (FEV1%)= The ratio of FEV1 to FVC (%) PEFR= Peak expiratory flow rate (L/secII or L/min) FEF 25% to 75%= Forced expiratory flow during middle half of FVC (L/sec or L/min)
  13. 13. Interpretation Normal Restrictive dis. Obstructive dis. Reversible obstruction (% predicted) (% predicted) (% predicted) after bronchodilator FVC >75 <75 <75 10-15%improvement FEV1 75 <75 <75 increase 200 ml FEV1/FVC 75-80 >85 <75 or 15% of beseline FEF25-75% >75-80 >85 <75 increase ≥ 20% Normal PFT: >75% of predicted value Mild disease: >65 but <75% of predicted value Moderate disease: >50% but <65% of predicted value Severe disease: <50% of predicted value
  14. 14. Example Case 1 Predicted value (L) Measured (L)value %Predicted FVC 6.00 4.00 67% FEV1 5.00 2.00 40% FEV1/FVC 83% 50% 60% Case 2 FVC 5.68 4.43 78% FEV1 4.90 3.52 72% FEV1/FVC 84% 79% 94% Case 3 FVC 3.20 2.48 77% FEV1 2.51 2.19 87% FEV1/FVC 78% 88% 115% Case 4 FVC 3.20 3.01 94% FEV1 2.51 1.19 47% FEV1/FVC 78 39 50%
  15. 15. Flow volume loops : the shape of the loop reflects the status of the lung volume and airways throughout the respiratory cycle. Characteristic changes occur in restrictive and in obstructive disorders. Normal Restrictive disease Asthma, COPD Upper airway obstruction
  16. 16. Treatment: short and long-term <ul><li>Long-term control medications : </li></ul><ul><ul><ul><li>Inhaled corticosteroids: Seretide, pulmicort </li></ul></ul></ul><ul><ul><ul><li>Long-acting beta 2 agonist: Serevent, Berodual </li></ul></ul></ul><ul><ul><ul><li>Leukotriene modifiers: montelukast (Singulair), </li></ul></ul></ul><ul><ul><ul><li>Theophylline </li></ul></ul></ul><ul><li>Quick-relief medication </li></ul><ul><ul><ul><li>Short-acting beta 2 agonist: Ventolin </li></ul></ul></ul><ul><ul><ul><li>Iprotropium (Atrovent) </li></ul></ul></ul><ul><ul><ul><li>Oral and intravenous corticosteroids </li></ul></ul></ul><ul><li>Immunotherapy </li></ul><ul><ul><ul><li>Allgergy desensitization for 3-5 yrs </li></ul></ul></ul><ul><li>Anti-Ig E monoclonal Ab : Omalizumab (Xolair) for </li></ul><ul><li>moderate to severe asthma </li></ul>
  17. 17. Assessment of asthma severity Intermittent Chronic persistent mild mild moderate severe Daytime symptoms (cough,tight chest, ≤ 2/week 2-4/week >4/week continuous wheeze) Night-time symptoms ≤ 1/month 2-4/month >4/month frequent PEF ≥ 80% ≥ 80% 60-80% < 60% Treatment B2-against PRN Inhaled cortio- Inhaled cortio- Inhaled cortio- steroid steroid steroid> 200-500 ug/d 500-1000 ug/d 1000 ug/d +/- B2-agonist PRN long acting B2 oral cortio- agonist or steroid +/- SR theophyllin long acting B2-against PRN B2agaist +/- SR theopphyllin B2-against PRN to 4-6 times/day
  18. 18. Refractory Asthma : 5-8% of total asthmatic population American thoracic society criteria for refractory asthma <ul><li>Major criteria </li></ul><ul><li>Treatment with oral corticosteroid ≥50% of the time </li></ul><ul><li>High dose of inhaled corticosteroid (≥ 1200 ug beclomethazone equivalent) </li></ul><ul><li>Minor criteria </li></ul><ul><li>Requirement for daily treatment with long-acting B 2 agonists, theophylline </li></ul><ul><li>or leukotriene antagonists </li></ul><ul><li>Daily asthmatic symptom requiring rescue medication </li></ul><ul><li>Persistent airway obstruction (FEV1<80% predicted), diurnal PEF </li></ul><ul><li>variability 20% </li></ul><ul><li>One or move urgent care visits for asthma per year </li></ul><ul><li>3 or more oral steroid bursts per year </li></ul><ul><li>Prompt deterioration with 25% reduction in oral or </li></ul><ul><li> inhaled corticosteroid dose </li></ul><ul><li>Near-fatal asthma event in the past </li></ul><ul><li>At least one major and two or more minor criteria are required for diagnosis . </li></ul>
  19. 19. Clinical pattern of severe (refractory) asthma <ul><li>Frequent severe exacerbations (Airway hyperresponsive) </li></ul><ul><li>precipitationg factors : infection, allergens exposure, </li></ul><ul><li>discontinuation of steroid, psychological dysfunciton, </li></ul><ul><li>GERD </li></ul><ul><li>Chronic persistent airflow limitation (Airway remodeling) </li></ul><ul><li>Risk factor : smoking, severity of childhood asthma, </li></ul><ul><li>adult onset </li></ul><ul><li>Corticosteroid dependence or resistance: </li></ul><ul><li>need> 30 mg of predmisolene </li></ul><ul><li>Rick factors : chronic use of B2-agonist, viral infection, </li></ul><ul><li>female </li></ul>
  20. 20. Differential Dx in severe refractory asthma <ul><ul><li>COPD </li></ul></ul><ul><ul><li>Bronchiectasis </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Central airway obstruction/compression by </li></ul></ul><ul><li>-FB -Tumor </li></ul><ul><li>-Sarcoidosis -Tbe </li></ul><ul><li>-Substernal goiter </li></ul><ul><ul><li>Recurrent PE </li></ul></ul><ul><ul><li>Vocal cord dysfunction </li></ul></ul><ul><ul><li>Hyperventilation syndrome </li></ul></ul><ul><ul><li>Allergic bronchopulmonary aspergillosis </li></ul></ul><ul><ul><li>Churg-Strauss syndrome </li></ul></ul>