The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.

1. Asthma

2. • 23 year old female with history of allergic
rhinitis complains of dyspnea and chest tightness
worse with exertion
• 65 year old male with 35 pack year history of
smoking complains of cough with sputum
expectoration and limitations in activity.
• What’s the diagnosis for the above cases?

3. Despite progress in understanding the
mechanisms of asthma,much is obscure
Asthma is a syndrome of signs, symptoms, and lab abnormalities but
probably represents multiple diseases
Clinical diagnosis is based on history of cough, wheeze, dyspnea, and
reversible airway obstruction
Our understanding of its pathogenesis is best worked out for allergic
asthma: but much asthma is not identifiably allergic “intrinsic asthma”

4. Defining features of asthma
• Variable airflow obstruction
• Airway hyper responsiveness to a variety of stimuli
• Inflammation in the airway

5. Risk factors for asthma
• ATOPY
• AGE
• ENGLISH LANGUAGE SPEAKING COUNTRIES
• FAMILY HISTORY OF ASTHMA
• 60% GENETIC BASIS IN IDENTICAL TWINS

6. AIRWAY INFLAMMATION IN ASTHMA
• THICKENING OF BASEMENT MEMBRANE
• INCREASED SMOOTH MUSCLE MASS
• SLOUGHING OF PSEUDOSTRATIFIED EPITHELIUM
• INCREASED GOBLET CELLS
• SUBMUCOSAL INFLAMMATION WITH EOSINOPHILS,
• LYMPHOCYTES, AND EDEMA
• INCREASED VASCULARITY

7. MICROSCOPIC ANATOMY OF ASTHMA

8. ALLERGIC MODEL FOR ASTHMA
• AEROALLERGEN EXPSOSURE TRIGGERS SPECIFIC IGE AB
• OVEREXPRESSION OF TH2 TYPE T CELL RESPONSE
• IGE AB BIND TO SURFACE RECEPTRS ON MAST CELLS
• RE-EXPOSURE TO ALLERGEN LEADS TO CROSS LINKING OF IGE
ANTIBODIES TRIGGERING MAST CELL DEGRANULATION AND
MEDIATOR RELEASE

9. EARLY PHASE REACTION: WITHIN
MINUTES
• SMOOTH MUSCLE CONTRACTION WITHIN SMALL AND LARGE
AIRWAYS PRODUCES RAPID INCREASE OF AIRWAY RESISTANCE
• INFLAMMATION RESULTS IN COUGH, MUCOUS RELEASE
• AIRWAY RESISTANCE RESULTS IN TACHYPNEA, TACHYCARDIA,
HYPERINFLATION OF LUNGS, SEVERE INCREASE IN WORK OF
BREATHING, FALL IN ALL AIR FLOW PARAMETERS
• MEDIATORS: HISTAMINE,PROSTAGLANDINS D2, CYSTEINYL
LEUKOTRIENES (LTC4, D4, AND E4)

10. LATE PHASE REACTION:4-6 HRS.
LATER
• COINCIDES WITH INFLUX OF T LYMPHOCYTES, EOSINOPHILS
AND BASOPHILS
• PLETHORA OF MEDIATORS ARE RELEASED
• EOSINOPHIL FACTORS: LEUKOTRIENES, PAF,MAJOR BASIC
PROTEIN,PEROXIDASE,EOSINOPHILIC CATIONIC
• PROTEIN,GRANULOCYTE MACROPHAGE COLONY STIMULATING
FACTOR,TRANSFORMING GROWTH FACTOR, INTERLEUKINS

11. Other players in the late phase reaction
• MAST CELLS:HISTAMINE, PROSTAGLANDINS,
LEUKOTRIENES,TNF ALPHA
• TH2 LYMPHOCYTES:CYTOKINES o: 3,4,5,13, GM-CSF, CHEMOKINE
RECPTORS
• NKT CELLS MAY MODULATE INFLAMMATION
• BASOPHILS: HISTAMINE, LEUOTRIENES, IL 11 AND 13.
• INNATE IMMUNE SYSTEM, AND EPITHELIALA AND
MESENCHYMAL CELLS MAY ALSO PARTICIPATE

12. MECHANISMS OF AIRWAY
OBSTRUCTION
• CONTRACTION OF AIRWAY SMOOTH MUSCLE
• THICKENING OF AIRWAYS DUE TO EDEMA AND INFLAMMATORY
CELLS
• PLUGGING OF AIRWAYS WITH MUCOUS AND CELLULAR DEBRIS
• AIRWAY REMODELING

13. AIRWAY HYPER-RESPONSIVENESS
• EXERCISE
• IRRITANTS IN AIR: SMOKE, PERFUME, CLEANING SUBSTANCES
• DRUGS SUCH AS METHACHOLINE
• COLD AIR

14. TYPES OF ASTHMA
• CHILDHOOD ASTHMA VS. ADULT ASTHMA
• ALLERGIC ASTHMA VS. INTRINSIC ASTHMA
• OCCUPATIONAL ASTHMA
• EXERCISE INDUCED ASTHMA
• ASPIRIN INDUCED ASTHMA
• COUGH EQUIVALENT ASTHMA
• FACTITIOUS ASTHMA

15. DIAGNOSIS OF ASTHMA
• HISTORY OF EPISODIC COUGH, WHEEZE, DYSPNEA, CHEST
TIGHTNESS, ESPECIALLY AT NIGHT
• HISTORY OF TWITCHY LUNGS: EXCESSIVE RESPONSE TO
EXERCISE, COLD AIR, ALLERGENS, POLLUTANTS, UPPER
AIRWAY INFECTIONS, FUMES, ODORS
• DOCUMENTATION OF REVERSIBLE AIRWAY OBSTRUCTION
• Eosinophil counts >5%, sputum eosinophilia or examination of sputum
for asthmatic elements occasionally helpful

16. NATURAL HISTORY OF ASTHMA
• CHILDHOOD ASTHMA TENDS TO REGRESS IN THE TEENS BUT
MAY RECUR AS AN ADULT
• ADULT ONSET ASTHMA IS USUALLY PERSISTENT
• SEVERE CHILDHOOD ASTHMA TENDS TO PERSIST
• ABOUT 30% OF INDIVIDUALS EXPERIENCE REMISSION
• UNKNOWN % PROGRESS TO IRREVERSIBLE OBSRUCTION
• U.S. PREVALANCE: ABOUT 8% OF POPULATION

17. ASTHMA AND THE WORLD
• WIDE RANGE OF ASTHMA :3.4% IN AFRICA,5.1% EASTERN
EUROPE, UP TO 25% IN ENGLISH LANGUAGE COUNTRIES
• HIGHEST U.S. INCIDENCE IN PUERTO RICO
• OVERALL TREND TO INCREASED INCIDENCE IN U.S. AND
WORLDWIDE
• OVERALL ASTHMA MORTALITY WAXES AND WANES

18. HYGIENE HYPOTHESIS
• WESTERN HOME HYGIENE MAY RESULT IN DELAY OF
EXPOSURE TO DIRT,BACTERIA, PARASITES,MOLDS .
• LATE EXPOSURE MAY TRIGGER HIGHER INCIDENCE OF
ALLERGIES/ASTHMA
• CHILDREN RAISED ON FARMS MAY HAVE HALF THE INCIDENCE
OF ASTHMA SEEN IN URBAN CHILDREN

19. MEDIATORS OF ACUTE ASTHMA
RESPONSE
• ACETYLCHOLINE FROM PULMONARY NERVE ENDINGS
• HISTAMINE: FROM MAST CELLS
• KININS:MAST CELLS-KALLIKREIN-CLEAVES BRADYKININ FROM
PLASMA PRECURSORS
• LEUKOTRIENES AND LIPOXINS: MAST
CELLS,EOSINOPHILS,MACROPHAGES
• NEUROPEPTIDES: FROM NERVE ENDINGS
• NO:EPITHELIAL CELLS,INFLAMMATORY CELLS:MARKER OF
ASTHMA
• PAF: MAST CELLS, EPITHELIAL CELLS

20. ROLE OF VIRUSES
• ONSET OF ASTHMA OFTEN FOLLOWS VIRUS ILLNESS
• RSV INFECTIONS MIMIC ASTHMA AND MAY BE FOLLOWED BY
PERSISTENT ASTHMA
• >50% EXACERBATIONS TRIGGERED BY VIRAL ILLNESS

21. PHYSIOLOGY OF ACUTE ATTACK
• RAPID RISE OF AIRWAY RESISTANCE
• IMMEDIATE INCREASE IN DEAD SPACE, TLC,DECREASED
ELASTIC RECOIL, TIDAL BREATHING AT HIGH VOLUME
• MARKED INCREASE IN PLEURAL PRESSURE:PULSUS
PARADOXICUS
• TACHYPNEA
• MARKED INCREASED WORK OF BREATHING TRIGGERS MUSCLE
FATIGUE

22. GAS EXCHANGE EFFECTS
• PATCHY AIRWAY CLOSURE RESULTS IN HIGH VARIABILITY OF
V/Q RATIOS AND HYPOXEMIA
• HYPERVENTILATION AND RESP. ALKALOSIS IS USUAL
RESPONSE
• SEVERE ATTACKS ONLY: EUCAPNEA OR HYPERCAPNEA
• VERY SEVERE ATTACKS:COMBINED RESP./METABOLIC ACIDOSIS

23. EXTRINSIC (ALLERGIC)ASTHMA
• MOSTLY IN CHILDHOOD
• ASSOCIATED WITH ATOPY,ECZEMA,FAMILY HISTORY
• ENVIRONMENTAL TRIGGERS: HOUSE DUST MITE,
PETS,ROACHES,SEASONAL ALLERGIC ATTACKS WITH POLLENS,
MOLDS
• POSITIVE SKIN TEST
• POSITIVE RAST ANTIBODIES

24. INTRINSIC ASTHMA
• ADULT ONSET
• NON-SPECIFIC TRIGGERS: VIRUSES,COLD AIR,EXERCISE,
FUMES,AIR POLLUTION: OFTEN NOT IDENTIFIABLE
• NEGATIVE SKIN TESTS AND RAST TEST
• NON-SEASONAL

25. OCCUPATIONAL ASTHMA
• LAB ANIMALS,CHICKENS, CRABS, PRAWNS, OYSTERS
• GRAIN DUST, WHEAT FLOUR,GUM ACACIA
• BIOLOGIC ENZYMES; TRYPSIN,PEPSIN, B. SUBTILIS
• METALS:PLATINUM, VANADIUM
• MISCELLANEOUS (>100):Toluene di-isocyanate in plastics,epoxy
resins, Western red cedar, formalin, urea, formaldehyde (insulation)

27. TREATMENT OF ASTHMA
• CORRECT DIAGNOSIS
• CATEGORIZE SEVERITY:INTERMITTENT; PERSISTENT: MILD,
MODERATE, OR SEVERE
• OBJECTIVE PHYSIOLOGIC MEASUREMENT(SPIROMETRY,PEAK
FLOW)
• EDUCATE PATIENT: PARTNERSHIP IN CARE
• IDENTIFY AND AVOID RISK FACTOTRS
• INDIVIDUAL MEDICATION PLAN AND FOLLOW-UP

28. SEVERITY OF ASTHMA
• INTERMITTENT: SYMPTOMS<1x/week, nocturnal
symptoms<2x/mo.,Peak Flow>80% predicted,<20% variability
• MILD PERSISTENT: symptoms>1x/wk<daily,nocturnal
symptoms>2x/mo;attacks affect activity,PF>80% but 20-30%
variability
• MODERATE PERSISTENT: daily symptoms, nocturnal symptoms
>1x/wk,attacks affect activity,PF60-80% with >30% variability
• SEVERE PERSISTENT:continuous symptoms,limited physical
activity,PF<60% with >30% variability

29. DRUGS FOR ASTHMA: CONTROLLERS
• CORTICOSTEROIDS: INHALED OR SYSTEMIC
• LONG ACTING BETA AGONISTS:FORMOTEROL,
SALMETEROL,OTHERS
• ANTILEUKOTRIENES: MONTELEUKAST
(SINGULAIR),ZAFIRLEUKAST (ACCOLATE), ZILEUTON
• SUSTAINED RELEASE THEOPHYLLINES
• SODIUM CROMOGLCYATE, NEDOCROMIL
• ANTI-IGE DRUG:OMALIZUMAB (XOLAIR)

30. DRUGS FOR ASTHMA: RELIEVERS
• SHORT ACTING BETA AGONISTS:
ALBUTEROL,LEVALBUTEROL,PIRBUTEROL,METAPROTERENOL,
TERBUTALINE,ISOETHARINE,EPINEPHRINE
• ANTICHOLINERGICS:IPRATROPIUM, LONG ACTING
TIOTROPIUM
• SHORT-ACTING THEOPHYLLINE
• EPINEPHRINE INJECTION OR TERBUTALINE INJECTION

31. STEPWISE TREATMENT
• INTERMITTENT: pt. education, PF meter, albuterol MDI
• MILD PERSISTENT: Low dose inhaled steroid +- leukotriene
blocker, sustained dose theophylline, cromolyn
• MODERATE PERSISTENT: low to medium dose inhaled
steroid, leukotriene blocker or cromolyn, consider long acting
beta agonist for limited period, consider theophylline
• SEVERE PERSISTENT: high dose inhaled steroid, long acting
beta agonist+- anticholinergic,theophylline, leukotriene blocker,
systemic steroids

32. ALLERGY MANAGMENT
• AVOIDANCE WHERE POSSIBLE
• HYPOSENSITIZATION THERAPY
• ENVIRONMENTAL CONTROLS

33. EKG in ASTHMA
• SINUS TACHYCARDIA
• RARELY CHANGES OF ACUTE RIGHT
VENTRICULAR OVERLOAD: RAD,RBBB, P
PULMONALE, NON SPECIFIC ST CHANGES

34. CHEST X RAY IN ASTHMA
• HYPERINFLATION IS USUAL CHANGE
• RARELY PNEUMOTHORAX,
PNEUMOMEDIASTINUM OR
PNEUMOPERICARDIUM
• BRONCHIECTASIS CHANGES IN ALLERGIC
BRONCHOPULMONARY ASPERGILLOSIS
WITH MUCOID IMPACTIONS VISIBLE

35. CHEST X RAY IN ASTHMA

36. ASTHMA PLAN FOR EVERY PATIENT
• DRUG LIST
• MONITORING PLAN AND GUIDELINES FOR
CHANGES IN THERAPY
• EMERGENCY NUMBERS
• INSTRUCTIONS ON WHAT TO DO FOR
WORSENING ASTHMA, WHEN TO PHONE, WHEN
TO CALL AMBULANCE, WHEN TO ADJUST
THERAPY

37. BASIC MANAGEMENT OF THE
ASTHMA PATIENT
• SEE WITH FREQUENCY DICTATED BY INDIVIDUAL
PATIENT HISTORY AND RISKS
• ASSESS PULMONARY FUNCTION AND SYMPTOMS AT
EVERY VISIT
• MAKE SURE PATIENT IS GETTING AND TAKING
MEDICATIONS
• REVIEW STATUS SINCE LAST VISIT: TRIGGERS,
NOCTURNAL SYMPTOMS, EXERCISE, WORK, MISSING
SCHOOL. FREQUENCY OF USE OF SHORT ACTING
BRONCHODILATORS

38. The difficult asthmatic
• FAILURE TO TAKE CONTROLLER DRUGS REGULARLY IS
MAJOR CAUSE
• REVIEW TRIGGERS; GO BACK OVER HISTORY
• CONSIDER CORTICOSTEROID RESISTANCE
• CHECK TECHNIQUES FOR USING INHALERS
• LOOK FOR SINUSITIS, GERD, AGGRAVATING
MEDICATIONS
• CONSIDER ALLEERGY TESTING
• CONSISDER ALLERGIC BRONCHOPULMONARY
ASPERGILLOSIS
• REVIEW OCCUPATIONAL FACTORS
• CONSIDER FACTITIOUS ASTHMA, AND UNDIAGNOSED
UPPER AIRWAY OBSTRUCTION

39. RISK FACTORS FOR SEVERE ASTHMA
• PRIOR MECHANICAL VENTILATION OR ICU ADMISSION
• 2 OR MORE HOSPITALIZATIONS IN LAST 12 MONTHS
• 3 OR MORE ED VISITS IN LAST YEAR
• HOSPITALIZATION OR ED RX WITHIN 1 MONTH
• USE OF MORE THAN 2 CANISTERS OF SHORT ACTING
BETA AGONIST/MO
• REQUIREMENT FOR ORAL PREDNISONE
• PSYCHIATRIC OR BEHAVIOR ISSUES; COMORBIDITIES

40. THERAPY OF THE ACUTE ATTACK
• SHORT ACTING ALBUTEROL: 4 PUFFS Q 10 MINUTES WITH
SPACER OR 5 MG.BY CONTINUE FLOW NEBULIZATION Q.
30 MINUTES
• LOW FLOW OXYGEN
• STEROIDS: EITHER 60 MGM. PREDNISONE P.O. OR
STANDARD DOSE iv SOLUMEDROL
• IPRATROPIUM IS A USEFUL ADD ON
• CONSIDER MAGNESIUM SULFATE 2 G. OVER 20 MINUTES
IV
• POSSIBLE THEOPHYLLINE USE (EVIDENCE MIXED ON
THIS)