HOPPING ALLAH ACCEPT THIS SMALL WORK

1. Asthma is really common and affects lots of people. It also causes lots of unnecessary
deaths, and a lot of hospital attendances from asthma attacks. The 2014 asthma guidelines
replace the word "exacerbation" with "attack" as it's easier to understand.
Asthma is defined as a chronic airway
inflammatory disorder with airway
hyper-responsiveness.
Asthma is an obstructive lung
condition, caused essentially by an
allergic reaction to a trigger. Like most
reactions, there is exposure that
sensitizes the helper T cells, then IgE is
produced, mast cells - and then you get
the response on the second and
subsequent exposure. The release of
histamines and leukotrienes causes
vasodilation, increased mucus
secretion and bronchial smooth
muscles contraction. The reaction also
causes eosinophils to migrate into the
airways, eyes and nose causing conjunctivitis, rhinitis and bronchiole constriction.
These features increase the probability of asthma:
- >1 of wheeze, cough, difficulty breathing, chest tightness
- particularly if the symptoms:
are worse at night/early morning
occur in response to exercise, allergen exposure or cold air
are triggered by aspirin or beta-blockers
occur in the absence of a cold
- Personal or family history of atopic disorder or asthma
- Widespread wheeze on chest auscultation
- Otherwise unexplained low FEV1 or PEFR
- Otherwise unexplained peripheral blood eosinophilia

3. These features lower the probability of asthma:
 Symptoms with colds only
 Chronic productive cough without wheeze or breathlessness
 Dizzyness, light-headedness or paraesthesia peripherally
 Voice disturbance
 Cardiac disease
 Significant smoking history (>20 pack years)
 Repeated normal chest examination when symptomatic
 Repeatedly normal PEFR or spirometry when symptomatic
Grading Systems
The SIGN (and British Thoracic Society) guidelines use clinical symptoms to grade the
severity of an attack in adults and children. The NICE guidelines appear to be based on the
SIGN guidelines.
Systolic paradox (pulsus paradoxus), an historical marker of severity of asthma, is
unhelpful and wastes valuable time so has been removed from the guidelines.
Features of patients at high risk of a life-threatening asthma attack:
1) Using a short-acting beta agonist inhaler more than once every four hours
2) Using more than one short-acting bronchodilator inhaler per month
3) Fewer than 12 prescriptions for preventer medication in the past year
4) Concurrent mental health problems

4. GRADING SYSTEM---asthma severity scoring system:
Factor Value for score of 0 Value for score of 1
Pulse rate ((beats / min)) < 120 >120
Respiratoey rate ((breaths/min)) < 30 >30
Pulsus paradoxus ((mmHg)) < 18 >18
Peak expiratory flow rate ((L/min)) >120 <120
Dyspnea Absent/ mild Moderate -sever
Accessory muscle rate Absent /mild Moderate -sever
Wheezing Absent-mild Moderate -sever
A score of 4 suggests sever asthma &may suggest the intensity of treatment required.
NOTE:
1. Sine respiratory alkalosis is the usual derangement in asthma ,PaCO2 that is
increasing toward normal indicate impending respiratory failure & the need for
frequent monitoring of ABG.
2. Metabolic acidosis is another ominous sign of impending respiratory failure
resulting from lactic acidosis due to fatiguing respiratory muscles.
3. PEFR <16% ((< 60L/min)) OR FEV1 < 0.6L should be considered severe asthma.
Investigations
Normally a clinical diagnosis, but if the patient has an intermediate probability of asthma,
investigations can help. The Calgary guide has a summary

5. Capnography
Wave form capnography should be used in acute exacerbations. Asthmatics get a "shark's
fin" appearance because of the broncho-constriction.

6. Spirometry shows reversibility and FEV1/FVC <0.7:
A decrease in FEV1 of > 15% after six minutes of exercise, or
An increase in FEV1 of > 15% after a two week trial of oral steroids (30 mg prednisolone
once
daily), or
An increase in FEV1 of > 15% following therapy with a short acting beta 2 agonist
You can calculate the percentage change in FEV1 by:
Subtract the pre-bronchodilator FEV1 from the post-bronchodilator FEV1
Divide this by the pre-bronchodilator FEV1
Multiply by 100.
Peak Flow

7. 60l/min. increase in PEFR) in response to either of the following strongly suggests
underlying asthma:
400 mcg inhaled salbutamol
6-week trial of steroid inhaler (beclometasone 200 mcg bd or equivalent)
CXR
- Normal in up to 75% of patients
- pulmonary hyperinflation
- bronchial wall thickening - peribronchial cuffing
(non specific finding but may be present in ~48% of cases with asthma)
- pulmonary oedema due to asthma
CT
To look for complicated associated conditions such as allergic bronchopulmonary
aspergillosis and not to directly diagnose asthma.
Non specific:
- bronchial wall thickening
- expiratory air trapping
- inspiratory decreased lung attenuation
- small centrilobular opacifities
- bronchial luminal narrowing - reduced
- bronchoarterial-diameter ratio
- sub segmental bronchiectasis - may be present in ~28-62% of asthmatics
Mimics
• Churg-Strauss
Look for signs and symptoms of systemic vasculitis, such as fever, weight loss, fatigue, and
malaise, Be suspicious if there is a persistent eosinophilia, positive ANCA, and multiorgan
involvement.

8. • COPD
Anaphylaxis
4% of asthma admissions to PICU almost certainly had anaphylaxis rather than asthma - so
make sure you consider it.
• Rhinitis
Management of chronic rhinosinusitis improves asthma control.
• Gastro-oesophageal reflux
Consider a three month trial of PPIs, as investigations to formally diagnose this are very
invasive.
• Inhaled foreign body
• Airway stenosis
• Bronchiectasis
• Sarcoidosis
• Lung cancer
• Obliterative bronchioloitis
• Congestive cardiac
failure
• Pulmonary embolus
• Pulmonary fibrosis
• Hyperventilation syndrome

9. • Chronic cough syndrome
• Vocal cord dysfunction
Occupational Asthma
Occupational factors probably account for 1 in 6 cases of asthma. It is more likely to develop
in the first year of exposure and is often preceeded by work related rhinitis. Symptoms
should improve away from work. If suspected, a referral to someone specialising in
occupational asthma should be made.
Compensation for occupational asthma is a complex area but The Citizens Advice Bureau
may offer advice about their eligibility for benefits and compensation.
National occupational asthma guidelines were published by the British Occupational Health
Research Foundation (BOHRF), updated in 2010.
BRONCHIAL ASTHMA:
NAEPP SYMPTOMS NIGHT TIME SYMPTOMS LUNG FUNCTION
MILD
INTERMITENT
Night < 2 /month
 Asymptomatic
 Symptoms ≤ 2 times a week
 Normal PEF B/W exacerbation
 Brief exacerbation(( hr-days))
 Intensity may vary
≤ 2 times/month
FEV1/PEF > 80%PREDICTED
PEF variability ≤ 20%
MILD
PERSISTENT
Night >2 /month
 Symptoms > 2 /week ,one < day
 Exacerbation may affect activity >2 times /month
FEV1/PEF 20---30%
PEF variability 20-30%
MODEARTE
PERSISTENT
Night > twice
/week
Daily symptoms
Daily short acting B2 agonist
Exacerbation affect activity
Exacerbation > 2 times /week
May last days
>1times a weak
>
b
>
>
PEF 60—80%
Variability >30%
SEVER
PERSISTENT
Night frequent
 Continual symptoms
 Limited physical activity
 Frequent exacerbations
frequent
PEF< 60 %
variability >30%
D/D:
1. COPD
2. GERD
3. WEGNERS GRANULOMATOSIS
4. CHURG STRAUSS SYNDROME
5. GERD
6. CARCINOID SYNDROM

10. 7. CARDIAC ASTHMA
8. UPPER AIR WAY OBSTRUCTION
9. RECURRENT PE
10. EOSINOPHILC PNEUMONIA
11. LOCALIZED WHEEZING ---STENOSIS ,FB ,TUMOR
Long term control Quick relief Education
MILD
INTERMETTENT
No daily medication Short acting B2 agonist
-TR depend on severity of
exerbation.
-use of Short acting B2 agonist >2
times /week may indicate the
need to institute long term
controltherapy
 Teach facts
 Teach inhalers
 Poles of
medication
 Develop self
management
 Environmental
control measures
MILD
PERSISTENT
No daily medication
Anti-inflammatory
1. Cromolyn/Nedocromil
2. Low dose inhaled steroids
Less desirable alternatives:
Theophyllin or leukotriene
modifier
1. Short acting B2
agonist as needed
for symptoms
2. TR depend on
severity of
exacerbation
3. B2 agonist inhaler on
daily basis or
increasing use
,indicate the need
for additional long
term control therapy
 Teach self
monitoring
 Group
education
 Self
management
plane
MODEARTE
PERSISTENT
Daily medication either:
ANTI-INFLAMMATORY (( C.S.
inhaler ((medium dose)) OR
Inhaled C.S. –low medium dose
and long acting bronchodilator
(( long acting B2 agonist inhaler
,sustained rlease theophyllin or
long acting B2 agonist tablets
IF NEEDE
Anti-inflammatory –inhaled CS(MHD)
Long acting inhaled B agonist;
sustained release theophyllin or long
acting B2 agonist tablets.
Short acting bronchodilator:
B2 agonist as needed for
symptoms.
TR depend on severity.
Use of short acting inhaler B2
agonist on daily basis or
increasing use
+
B2 agonist tablet.Long term
control therapy
 Step 1
 +
 Teach self
monitoring
 Group
education self
management
plan
SEVER
PERSISTENT
Long term control
Daily medication—
High dose inhaled corticosteroids
or
Long acting bronchodilator-LABA
Sustained release theophyllin or
long acting B2 agonist
And
Corticosteroids tablet 2mg/kg/day
Inhaled B agonist as needed
TR depend on exacerbation
Short acting inhaler B agonist on
daily basis or increasing use
indicate need for long use
Short acting B2 agonist:
1. Albuterol---proventril ,ventolin
2. Albuterol HFA

11. 3. Terbutaline