Exercise-induced bronchoconstriction (EIB) is the transient narrowing of the lower airways that occurs after vigorous exercise in individuals both with and without asthma. It is triggered by factors like cold air, pollutants, and allergens during exercise. Diagnosis involves a history of acute symptoms after exercise and objective testing like exercise challenge tests, which measure any drop in lung function after exercise. Treatment focuses on preventing symptoms through proper warm-ups, medication, and avoiding triggers during exercise.
The document discusses the diagnostic approach and treatment of interstitial lung disease (ILD). ILD refers to over 100 lung disorders that share clinical features and affect the lung interstitium. The evaluation of ILD involves obtaining a thorough medical history focusing on exposures, symptoms, and underlying conditions. Physical exams may reveal crackles or clubbing. Tests include pulmonary function tests, imaging, and tissue sampling. Treatment depends on the underlying cause but may include immunosuppressants, antifibrotic drugs, oxygen therapy, and lung transplantation. A multidisciplinary team is needed for accurate diagnosis and management of ILD.
Biologic therapies target specific inflammatory pathways involved in asthma. Omalizumab targets IgE and is approved for severe allergic asthma. It reduces exacerbations and lowers corticosteroid needs. Mepolizumab targets IL-5 and reduces exacerbations in severe eosinophilic asthma. Anti-IL-4/IL-13 and anti-IL-17 therapies are also under investigation. While biologics show promise for uncontrolled asthma, their high cost, parenteral administration, and potential adverse effects limit broader use. Accurate patient phenotyping is key to matching the right therapy.
Asthma management phenotype based approachGamal Agmy
Phenotypes and endotypes are approaches to classifying asthma subtypes based on clinical characteristics and underlying biological mechanisms. The document discusses several potential asthma endotypes including:
1) TH2-high endotypes like early-onset allergic asthma characterized by genetics predisposing to TH2 cytokines, biomarkers like elevated IgE and eosinophils, and response to anti-IgE therapy.
2) Late-onset eosinophilic asthma characterized by persistent sputum eosinophilia despite steroids and potential response to anti-IL5 therapy.
3) Aspirin-exacerbated respiratory disease which may be a similar endotype to intrinsic or allergic asthma due to acquired NSA
This document discusses asthma phenotypes and endotypes. It defines asthma as a chronic inflammatory airway disease characterized by variable airflow obstruction and airway hyperresponsiveness. Asthma phenotypes are subtypes defined by clinical characteristics, while endotypes are subtypes defined by underlying pathophysiology and biomarkers. The document describes several asthma phenotypes including early-onset allergic asthma, late-onset eosinophilic asthma, aspirin-exacerbated respiratory disease, exercise-induced asthma, and obesity-related asthma. It also discusses non-Th2 endotypes such as neutrophilic asthma and smoking-related asthma. The document emphasizes moving toward personalized treatment based on individual endotypes.
Bronchial Asthma- Recent advances in management by Dr. Jebin AbrahamJebin Abraham
Bronchial asthma, Asthma phenotypes, newer bronchodilators, personalised medicine in asthma, pharmacogenetics of current drugs, immunotherapy, vaccination, bronchial thermoplasty, surgical management
This document discusses bronchial hyperresponsiveness and bronchial provocation tests. It begins by defining asthma as a chronic inflammatory airway disease characterized by variable airflow obstruction and hyperresponsiveness to triggers. Bronchial hyperresponsiveness is an abnormal increase in airflow limitation following exposure to a stimulus and can be quantified using bronchial provocation tests. Several types of direct and indirect stimuli are described for use in bronchial provocation tests, with methacholine challenge being the most commonly used direct stimulus test due to its safety and sensitivity. The document outlines the procedures, interpretations, and indications for various bronchial provocation tests.
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
The document discusses the diagnostic approach and treatment of interstitial lung disease (ILD). ILD refers to over 100 lung disorders that share clinical features and affect the lung interstitium. The evaluation of ILD involves obtaining a thorough medical history focusing on exposures, symptoms, and underlying conditions. Physical exams may reveal crackles or clubbing. Tests include pulmonary function tests, imaging, and tissue sampling. Treatment depends on the underlying cause but may include immunosuppressants, antifibrotic drugs, oxygen therapy, and lung transplantation. A multidisciplinary team is needed for accurate diagnosis and management of ILD.
Biologic therapies target specific inflammatory pathways involved in asthma. Omalizumab targets IgE and is approved for severe allergic asthma. It reduces exacerbations and lowers corticosteroid needs. Mepolizumab targets IL-5 and reduces exacerbations in severe eosinophilic asthma. Anti-IL-4/IL-13 and anti-IL-17 therapies are also under investigation. While biologics show promise for uncontrolled asthma, their high cost, parenteral administration, and potential adverse effects limit broader use. Accurate patient phenotyping is key to matching the right therapy.
Asthma management phenotype based approachGamal Agmy
Phenotypes and endotypes are approaches to classifying asthma subtypes based on clinical characteristics and underlying biological mechanisms. The document discusses several potential asthma endotypes including:
1) TH2-high endotypes like early-onset allergic asthma characterized by genetics predisposing to TH2 cytokines, biomarkers like elevated IgE and eosinophils, and response to anti-IgE therapy.
2) Late-onset eosinophilic asthma characterized by persistent sputum eosinophilia despite steroids and potential response to anti-IL5 therapy.
3) Aspirin-exacerbated respiratory disease which may be a similar endotype to intrinsic or allergic asthma due to acquired NSA
This document discusses asthma phenotypes and endotypes. It defines asthma as a chronic inflammatory airway disease characterized by variable airflow obstruction and airway hyperresponsiveness. Asthma phenotypes are subtypes defined by clinical characteristics, while endotypes are subtypes defined by underlying pathophysiology and biomarkers. The document describes several asthma phenotypes including early-onset allergic asthma, late-onset eosinophilic asthma, aspirin-exacerbated respiratory disease, exercise-induced asthma, and obesity-related asthma. It also discusses non-Th2 endotypes such as neutrophilic asthma and smoking-related asthma. The document emphasizes moving toward personalized treatment based on individual endotypes.
Bronchial Asthma- Recent advances in management by Dr. Jebin AbrahamJebin Abraham
Bronchial asthma, Asthma phenotypes, newer bronchodilators, personalised medicine in asthma, pharmacogenetics of current drugs, immunotherapy, vaccination, bronchial thermoplasty, surgical management
This document discusses bronchial hyperresponsiveness and bronchial provocation tests. It begins by defining asthma as a chronic inflammatory airway disease characterized by variable airflow obstruction and hyperresponsiveness to triggers. Bronchial hyperresponsiveness is an abnormal increase in airflow limitation following exposure to a stimulus and can be quantified using bronchial provocation tests. Several types of direct and indirect stimuli are described for use in bronchial provocation tests, with methacholine challenge being the most commonly used direct stimulus test due to its safety and sensitivity. The document outlines the procedures, interpretations, and indications for various bronchial provocation tests.
Bronchial Thermoplasty (BT) Novel Treatment for Patients with Severe AsthmaBassel Ericsoussi, MD
Do our Asthma Patients Know What They Are Missing?Now, A Revolutionary Procedure Can Help Them Lead A Fuller Life.
Bronchial Thermoplasty (BT) Novel Treatment For Patients With Severe Asthma
DLCO/TLCO measures the ability of the lungs to transfer carbon monoxide from the alveoli to the blood. It estimates the surface area and thickness of the alveolar-capillary membrane. CO is used instead of oxygen because its transfer is diffusion limited and it binds readily to hemoglobin. A single-breath hold method is most common where the patient inhales a gas mixture and holds their breath for 10 seconds while CO uptake is measured. DLCO can help identify interstitial lung diseases, emphysema, pulmonary hypertension and assess treatment response. Reduced DLCO may be due to decreased surface area from conditions like emphysema, or increased membrane thickness from fibrosis. Adjustments are made
Respiratory diseases are leading causes of death worldwide. Patients with chronic lung diseases are at risk of hypoxemia during air travel due to lower oxygen levels at high altitudes. The document provides guidance on evaluating fitness to fly for various respiratory conditions through tests such as pulse oximetry, hypoxemia prediction equations, 6-minute walk tests, and hypoxia altitude simulation tests. Conditions that generally contraindicate air travel include active pneumothorax, severe pulmonary hypertension, and uncontrolled asthma. Pre-travel evaluation is advised for patients with COPD, ILD, cystic fibrosis or other lung diseases.
Management of severe asthma an update 2014avicena1
This document discusses the management of severe asthma. It begins by defining several phenotypes of severe asthma, including refractory asthma and steroid-dependent asthma. It then reviews the diagnostic criteria for severe asthma established by the American Thoracic Society and European Respiratory Society, which requires one or more major criteria and two or more minor criteria. The document further discusses approaches to diagnosing and treating severe asthma, including evaluating for alternative diagnoses, assessing treatment compliance and triggers, addressing comorbidities, and considering immunotherapy options. It emphasizes the importance of phenotyping and endotyping asthma to enable personalized treatment approaches.
The document outlines different types of bronchial challenge tests used to evaluate airway hyperresponsiveness. It discusses direct challenge tests like methacholine challenge tests which act directly on airway smooth muscle. It also discusses indirect challenge tests like exercise and eucapnic voluntary hyperpnea which act through intermediate pathways. The document provides details on performing methacholine challenge tests using either a two-minute tidal breathing dosing protocol or a five-breath dosimeter protocol.
An update on the management of Idiopathic Pulmonary Fibrosis (IPF)Sarfraz Saleemi
This document provides a historical overview and update on the management of idiopathic pulmonary fibrosis (IPF). It discusses the evolution of IPF diagnosis and classification over time based on clinical and pathological criteria. Key risk factors for IPF like older age, family history, smoking and genetics are summarized. The document also reviews prognostic indicators, comorbidities, current pharmacological therapies including pirfenidone and nintedanib, and the multidisciplinary approach to diagnosis and management of IPF.
This document discusses inhaled corticosteroids (ICS), including their pharmacokinetics, mechanisms of action, and clinical use for asthma. Some key points:
1) ICS are synthetic glucocorticoids modified to have higher receptor affinity and potency, and faster metabolism to reduce systemic side effects. They work through both genomic and non-genomic pathways to reduce lung inflammation.
2) Pharmacokinetically, ICS vary in their absorption, distribution, metabolism and excretion properties which influence their potency, duration of action, and systemic absorption levels. More lipophilic ICS like fluticasone are retained longer in the lungs.
3) Clinically, low
This document provides an overview of asthma-COPD overlap syndrome (ACOS). It discusses how asthma and COPD were traditionally viewed as distinct conditions but some patients exhibit features of both. Patients with ACOS have worse health outcomes than those with asthma or COPD alone. The document reviews clinical features of ACOS and provides guidance on diagnosing patients based on their symptoms, lung function tests, and other features. It also discusses treatment approaches for ACOS.
Asthma is a heterogeneous disease with different phenotypes and endotypes. Severe asthma is a subset of difficult-to-treat asthma that remains uncontrolled despite maximal optimized treatment. Cluster analysis has identified several asthma phenotypes including eosinophilic phenotypes characterized by type 2 inflammation as well as non-type 2 phenotypes. Biomarkers can help identify patients with type 2 inflammation who may benefit from targeted biologic therapies.
- Administered questionnaires
- Performed skin prick tests to common aeroallergens
- Collected blood samples for total IgE & specific IgE
FENO measurement:
- Using NIOX MINO ( Aerocrine AB, Solna, Sweden)
- According to ATS/ERS guidelines
JACI. 2011; 127 ( 5) : 1165-72.e5.
Allergic sensitization:
- Positive SPT ( wheal diameter ≥ 3 mm) to at least one allergen
- Or specific IgE ≥ 0.35 kU/L to at least one allergen
Asthma:
Pulmonary function test in children (spirometer)Azad Haleem
Spirometry is a noninvasive pulmonary function test that measures lung volumes and airflow. It is useful for diagnosing and monitoring respiratory diseases like asthma in children who are able to perform the test properly. Key measurements include forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and ratios like FEV1/FVC. Obstructive patterns show reduced airflow while restrictive patterns show reduced lung volumes. Spirometry provides objective data to guide treatment and monitor response to medications like bronchodilators.
The document discusses interstitial lung diseases (ILDs) and diffuse parenchymal lung diseases (DPLDs). It defines the lung interstitium and its three subdivisions. It describes the approach to evaluating ILDs, which involves radiologists, pathologists and pulmonologists. ILDs can be classified as those of known cause, idiopathic interstitial pneumonias, granulomatous diseases, and other rare forms. Common idiopathic interstitial pneumonias are also outlined. The document reviews clinical assessment of ILDs including history, exam, imaging and lung function testing.
This document provides an overview of interstitial lung disease (ILD). ILD encompasses over 200 lung disorders that involve scarring or damage to the lungs' interstitium. Progressive fibrosis can occur in some ILDs and is associated with worse outcomes. Idiopathic pulmonary fibrosis is the most common progressive ILD and is characterized by lung scarring. Progressive-fibrosing ILD describes patients with fibrotic ILDs that may deteriorate despite treatment. Diagnosis involves evaluating symptoms, imaging, pulmonary function tests, biopsies and labs to identify the specific ILD and develop a treatment plan which may include immunosuppressants or removing environmental exposures.
A 68-year-old Saudi man presented with chronic cough, shortness of breath, and wheezing for 5 years. Imaging showed right middle lobe bronchial thickening and distal collapse. Bronchoscopy found asthma-related changes. Laboratory results showed eosinophilia. He was diagnosed with right middle lobe syndrome due to severe asthma. Treatment involved aggressive asthma management, chest physiotherapy, antibiotics for exacerbations, and potential lobectomy for complications.
This document discusses the approach to interstitial lung diseases (ILD) and diffuse parenchymal lung diseases (DPLD). It begins by reviewing the spectrum of ILD and DPLD, identifying clues from clinical presentation to make a diagnosis, and reviewing common radiographic findings. Key points include that ILD involves the pulmonary interstitium located between the epithelial and endothelial basement membranes. Clinical presentation of DPLD/ILD often involves dyspnea, cough, and abnormal chest imaging. Diagnosis involves considering history, physical exam, pulmonary function tests, imaging like chest radiographs and CT, and tissue sampling. Management depends on the specific diagnosis but may include treatments like corticosteroids, immunosuppressants, anti
This document summarizes information about asthma phenotypes from several sources. It begins by defining asthma as a heterogeneous disease characterized by chronic airway inflammation and variable airflow limitation. Phenotypes are the observable characteristics of a disease, and examples of asthma phenotypes include allergic asthma, non-allergic asthma, and obesity-related asthma. Endotypes are disease subtypes defined by distinct molecular mechanisms. Biomarkers can help identify phenotypes and predict treatment responses. The document then reviews biomarkers and features of eosinophilic versus non-eosinophilic asthma and discusses mechanisms and treatment approaches for different phenotypes.
The document discusses basic principles of mechanical ventilation including factors that can lead to ventilatory failure, airway resistance, lung compliance, hypoventilation, V/Q mismatch, intrapulmonary shunting, and diffusion defects. It also covers different types of ventilator waveforms including pressure, volume, flow and pressure/volume loops which can be used to assess a patient's respiratory status and response to therapy.
Respiratory physiology on airway resistance Faez Toushiro
1. The document outlines the relationships between airflow, pressure, and resistance in the conducting airways and the effects of various substances.
2. Catecholamines like epinephrine cause bronchodilation through adrenergic receptors while cholinergic agonists like carbachol cause bronchoconstriction.
3. Histamine causes bronchoconstriction through H1 receptors by increasing mucus and vascular permeability. Prostaglandins have dual effects with prostacycline causing bronchodilation and PGE2 having both constricting and dilating effects.
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to the fungus Aspergillus fumigatus in patients with asthma or cystic fibrosis. It occurs in 1-2% of asthmatics and 1-15% of cystic fibrosis patients. Clinical features include recurrent asthma exacerbations, cough, wheezing and blood-stained sputum. Diagnosis is based on clinical criteria and elevated IgE levels. Treatment involves oral corticosteroids, antifungal agents like itraconazole, and omalizumab for severe cases. Prognosis depends on early diagnosis and treatment to prevent lung damage.
The Global Initiative for Asthma (GINA) is an independent organization established by the WHO and NHLBI in 1993 to increase awareness of asthma and improve asthma prevention and management through coordinated global efforts. GINA publishes annual evidence-based strategy reports that provide practical guidance on asthma diagnosis and treatment that can be adapted for local health systems. The 2022 report includes updates to the diagnostic approach for patients taking controller treatment and emphasizes using low-dose ICS-formoterol as reliever therapy to reduce exacerbation risk compared to SABA relievers.
This document discusses exercise-induced bronchoconstriction (EIB). It begins with definitions of EIB and related terms. It then covers the clinical presentation of EIB, including typical symptoms and atypical presentations. The pathogenesis section explores various theories for the mechanisms underlying EIB, such as thermal and osmotic theories. Risk factors, prevalence, diagnosis, and treatment of EIB are also addressed.
The document discusses exercise-induced bronchoconstriction (EIB). It defines EIB as a transient narrowing of the lower airways that occurs after vigorous exercise. The prevalence of EIB is 7-20% in the general population and up to 90% in asthma patients. The pathogenesis involves heat and water moving from the airway mucosa during exercise, leading to osmotic and thermal changes that cause bronchoconstriction. Diagnosis involves objective tests like exercise challenges, eucapnic voluntary hyperpnea, or inhaled mannitol challenges to detect a drop in lung function after exercise or hyperventilation. Treatment focuses on preventative bronchodilator medication use before exercise.
DLCO/TLCO measures the ability of the lungs to transfer carbon monoxide from the alveoli to the blood. It estimates the surface area and thickness of the alveolar-capillary membrane. CO is used instead of oxygen because its transfer is diffusion limited and it binds readily to hemoglobin. A single-breath hold method is most common where the patient inhales a gas mixture and holds their breath for 10 seconds while CO uptake is measured. DLCO can help identify interstitial lung diseases, emphysema, pulmonary hypertension and assess treatment response. Reduced DLCO may be due to decreased surface area from conditions like emphysema, or increased membrane thickness from fibrosis. Adjustments are made
Respiratory diseases are leading causes of death worldwide. Patients with chronic lung diseases are at risk of hypoxemia during air travel due to lower oxygen levels at high altitudes. The document provides guidance on evaluating fitness to fly for various respiratory conditions through tests such as pulse oximetry, hypoxemia prediction equations, 6-minute walk tests, and hypoxia altitude simulation tests. Conditions that generally contraindicate air travel include active pneumothorax, severe pulmonary hypertension, and uncontrolled asthma. Pre-travel evaluation is advised for patients with COPD, ILD, cystic fibrosis or other lung diseases.
Management of severe asthma an update 2014avicena1
This document discusses the management of severe asthma. It begins by defining several phenotypes of severe asthma, including refractory asthma and steroid-dependent asthma. It then reviews the diagnostic criteria for severe asthma established by the American Thoracic Society and European Respiratory Society, which requires one or more major criteria and two or more minor criteria. The document further discusses approaches to diagnosing and treating severe asthma, including evaluating for alternative diagnoses, assessing treatment compliance and triggers, addressing comorbidities, and considering immunotherapy options. It emphasizes the importance of phenotyping and endotyping asthma to enable personalized treatment approaches.
The document outlines different types of bronchial challenge tests used to evaluate airway hyperresponsiveness. It discusses direct challenge tests like methacholine challenge tests which act directly on airway smooth muscle. It also discusses indirect challenge tests like exercise and eucapnic voluntary hyperpnea which act through intermediate pathways. The document provides details on performing methacholine challenge tests using either a two-minute tidal breathing dosing protocol or a five-breath dosimeter protocol.
An update on the management of Idiopathic Pulmonary Fibrosis (IPF)Sarfraz Saleemi
This document provides a historical overview and update on the management of idiopathic pulmonary fibrosis (IPF). It discusses the evolution of IPF diagnosis and classification over time based on clinical and pathological criteria. Key risk factors for IPF like older age, family history, smoking and genetics are summarized. The document also reviews prognostic indicators, comorbidities, current pharmacological therapies including pirfenidone and nintedanib, and the multidisciplinary approach to diagnosis and management of IPF.
This document discusses inhaled corticosteroids (ICS), including their pharmacokinetics, mechanisms of action, and clinical use for asthma. Some key points:
1) ICS are synthetic glucocorticoids modified to have higher receptor affinity and potency, and faster metabolism to reduce systemic side effects. They work through both genomic and non-genomic pathways to reduce lung inflammation.
2) Pharmacokinetically, ICS vary in their absorption, distribution, metabolism and excretion properties which influence their potency, duration of action, and systemic absorption levels. More lipophilic ICS like fluticasone are retained longer in the lungs.
3) Clinically, low
This document provides an overview of asthma-COPD overlap syndrome (ACOS). It discusses how asthma and COPD were traditionally viewed as distinct conditions but some patients exhibit features of both. Patients with ACOS have worse health outcomes than those with asthma or COPD alone. The document reviews clinical features of ACOS and provides guidance on diagnosing patients based on their symptoms, lung function tests, and other features. It also discusses treatment approaches for ACOS.
Asthma is a heterogeneous disease with different phenotypes and endotypes. Severe asthma is a subset of difficult-to-treat asthma that remains uncontrolled despite maximal optimized treatment. Cluster analysis has identified several asthma phenotypes including eosinophilic phenotypes characterized by type 2 inflammation as well as non-type 2 phenotypes. Biomarkers can help identify patients with type 2 inflammation who may benefit from targeted biologic therapies.
- Administered questionnaires
- Performed skin prick tests to common aeroallergens
- Collected blood samples for total IgE & specific IgE
FENO measurement:
- Using NIOX MINO ( Aerocrine AB, Solna, Sweden)
- According to ATS/ERS guidelines
JACI. 2011; 127 ( 5) : 1165-72.e5.
Allergic sensitization:
- Positive SPT ( wheal diameter ≥ 3 mm) to at least one allergen
- Or specific IgE ≥ 0.35 kU/L to at least one allergen
Asthma:
Pulmonary function test in children (spirometer)Azad Haleem
Spirometry is a noninvasive pulmonary function test that measures lung volumes and airflow. It is useful for diagnosing and monitoring respiratory diseases like asthma in children who are able to perform the test properly. Key measurements include forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and ratios like FEV1/FVC. Obstructive patterns show reduced airflow while restrictive patterns show reduced lung volumes. Spirometry provides objective data to guide treatment and monitor response to medications like bronchodilators.
The document discusses interstitial lung diseases (ILDs) and diffuse parenchymal lung diseases (DPLDs). It defines the lung interstitium and its three subdivisions. It describes the approach to evaluating ILDs, which involves radiologists, pathologists and pulmonologists. ILDs can be classified as those of known cause, idiopathic interstitial pneumonias, granulomatous diseases, and other rare forms. Common idiopathic interstitial pneumonias are also outlined. The document reviews clinical assessment of ILDs including history, exam, imaging and lung function testing.
This document provides an overview of interstitial lung disease (ILD). ILD encompasses over 200 lung disorders that involve scarring or damage to the lungs' interstitium. Progressive fibrosis can occur in some ILDs and is associated with worse outcomes. Idiopathic pulmonary fibrosis is the most common progressive ILD and is characterized by lung scarring. Progressive-fibrosing ILD describes patients with fibrotic ILDs that may deteriorate despite treatment. Diagnosis involves evaluating symptoms, imaging, pulmonary function tests, biopsies and labs to identify the specific ILD and develop a treatment plan which may include immunosuppressants or removing environmental exposures.
A 68-year-old Saudi man presented with chronic cough, shortness of breath, and wheezing for 5 years. Imaging showed right middle lobe bronchial thickening and distal collapse. Bronchoscopy found asthma-related changes. Laboratory results showed eosinophilia. He was diagnosed with right middle lobe syndrome due to severe asthma. Treatment involved aggressive asthma management, chest physiotherapy, antibiotics for exacerbations, and potential lobectomy for complications.
This document discusses the approach to interstitial lung diseases (ILD) and diffuse parenchymal lung diseases (DPLD). It begins by reviewing the spectrum of ILD and DPLD, identifying clues from clinical presentation to make a diagnosis, and reviewing common radiographic findings. Key points include that ILD involves the pulmonary interstitium located between the epithelial and endothelial basement membranes. Clinical presentation of DPLD/ILD often involves dyspnea, cough, and abnormal chest imaging. Diagnosis involves considering history, physical exam, pulmonary function tests, imaging like chest radiographs and CT, and tissue sampling. Management depends on the specific diagnosis but may include treatments like corticosteroids, immunosuppressants, anti
This document summarizes information about asthma phenotypes from several sources. It begins by defining asthma as a heterogeneous disease characterized by chronic airway inflammation and variable airflow limitation. Phenotypes are the observable characteristics of a disease, and examples of asthma phenotypes include allergic asthma, non-allergic asthma, and obesity-related asthma. Endotypes are disease subtypes defined by distinct molecular mechanisms. Biomarkers can help identify phenotypes and predict treatment responses. The document then reviews biomarkers and features of eosinophilic versus non-eosinophilic asthma and discusses mechanisms and treatment approaches for different phenotypes.
The document discusses basic principles of mechanical ventilation including factors that can lead to ventilatory failure, airway resistance, lung compliance, hypoventilation, V/Q mismatch, intrapulmonary shunting, and diffusion defects. It also covers different types of ventilator waveforms including pressure, volume, flow and pressure/volume loops which can be used to assess a patient's respiratory status and response to therapy.
Respiratory physiology on airway resistance Faez Toushiro
1. The document outlines the relationships between airflow, pressure, and resistance in the conducting airways and the effects of various substances.
2. Catecholamines like epinephrine cause bronchodilation through adrenergic receptors while cholinergic agonists like carbachol cause bronchoconstriction.
3. Histamine causes bronchoconstriction through H1 receptors by increasing mucus and vascular permeability. Prostaglandins have dual effects with prostacycline causing bronchodilation and PGE2 having both constricting and dilating effects.
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to the fungus Aspergillus fumigatus in patients with asthma or cystic fibrosis. It occurs in 1-2% of asthmatics and 1-15% of cystic fibrosis patients. Clinical features include recurrent asthma exacerbations, cough, wheezing and blood-stained sputum. Diagnosis is based on clinical criteria and elevated IgE levels. Treatment involves oral corticosteroids, antifungal agents like itraconazole, and omalizumab for severe cases. Prognosis depends on early diagnosis and treatment to prevent lung damage.
The Global Initiative for Asthma (GINA) is an independent organization established by the WHO and NHLBI in 1993 to increase awareness of asthma and improve asthma prevention and management through coordinated global efforts. GINA publishes annual evidence-based strategy reports that provide practical guidance on asthma diagnosis and treatment that can be adapted for local health systems. The 2022 report includes updates to the diagnostic approach for patients taking controller treatment and emphasizes using low-dose ICS-formoterol as reliever therapy to reduce exacerbation risk compared to SABA relievers.
This document discusses exercise-induced bronchoconstriction (EIB). It begins with definitions of EIB and related terms. It then covers the clinical presentation of EIB, including typical symptoms and atypical presentations. The pathogenesis section explores various theories for the mechanisms underlying EIB, such as thermal and osmotic theories. Risk factors, prevalence, diagnosis, and treatment of EIB are also addressed.
The document discusses exercise-induced bronchoconstriction (EIB). It defines EIB as a transient narrowing of the lower airways that occurs after vigorous exercise. The prevalence of EIB is 7-20% in the general population and up to 90% in asthma patients. The pathogenesis involves heat and water moving from the airway mucosa during exercise, leading to osmotic and thermal changes that cause bronchoconstriction. Diagnosis involves objective tests like exercise challenges, eucapnic voluntary hyperpnea, or inhaled mannitol challenges to detect a drop in lung function after exercise or hyperventilation. Treatment focuses on preventative bronchodilator medication use before exercise.
This document discusses asthma phenotypes and endotypes. It begins by describing how cluster analysis of clinical characteristics can group asthma patients into phenotypes. Molecular approaches are evolving to identify specific biological pathways (endotypes) that explain observable phenotypes. Eosinophilic and non-eosinophilic asthma are two major phenotypes. Eosinophilic asthma is characterized by high sputum or blood eosinophil levels and often responds to inhaled corticosteroids or biologics targeting cytokines like IL-5. Non-eosinophilic asthma involves other inflammatory cells like neutrophils. The document reviews cluster analyses and potential endotypes driving different asthma phenotypes.
This document discusses various asthma phenotypes or endotypes that have been identified based on differences in clinical characteristics, biomarkers and treatment responses. The two main endotypes discussed are TH2-high asthma and non-TH2 asthma. TH2-high asthma includes early-onset allergic asthma, late-onset eosinophilic asthma and exercise-induced asthma. It is characterized by eosinophilia, TH2 biomarkers and good response to corticosteroids and anti-TH2 targeted therapies. Non-TH2 asthma includes obesity-related asthma, neutrophilic asthma and smoking asthma. It has fewer clinical allergies and TH2 biomarkers, and poorer responses to corticosteroids. Distinct clinical features, genetics,
Asthma is a chronic inflammatory disease of the airways that can present as different phenotypes or endotypes. The document discusses two main endotypes: TH2-high and non-TH2. The TH2-high endotype includes early-onset allergic asthma, late-onset eosinophilic asthma, and exercise-induced asthma. It is characterized by atopy, eosinophilia, response to corticosteroids, and biomarkers showing TH2 pathway activation. The non-TH2 endotype includes approximately 50% of asthma patients and its pathobiology is less clear but may involve mixed inflammatory processes beyond TH2 immunity alone.
Asthma is a very common condition affecting around 1 in 11 children. It places a large disease burden due to associated morbidity and mortality. Effective management of asthma requires regular review to assess control, inhaler technique, patient understanding and compliance, and to question the accuracy of the diagnosis.
The document discusses an update on asthma presented by Dr. Joseph A. Aluoch, covering topics such as the heterogeneity of asthma phenotypes, the importance of establishing a diagnosis and differentiating asthma from other conditions, goals of asthma management including improving control and reducing risk of exacerbations, and therapeutic strategies such as patient education.
Exercise-induced asthma (EIA) and bronchospasm are triggered by exercise in patients with or without chronic asthma. EIA is diagnosed when exercise causes a 15% decrease in lung function and symptoms start after exercise and resolve within 60 minutes. It is common, affecting 10-20% of the general population and up to 90% of asthmatics. Treatment includes warm-up/cool-down periods, medication before exercise like bronchodilators, and ensuring proper asthma management.
Occupational asthma can be caused by sensitizers or irritants encountered in the workplace. It is important to consider occupational asthma in cases of new adult-onset or worsening asthma. Diagnosis involves confirming objectively that symptoms are work-related and improve away from work, such as through monitoring lung function at and away from work or specific inhalation challenges. Early diagnosis and removal from exposure leads to the best outcomes, with complete avoidance necessary for sensitizer-induced occupational asthma.
This document discusses approaches to asthma and newer modalities in treatment. It begins by defining asthma as a chronic airway inflammation disease characterized by variable respiratory symptoms. It then discusses triggers of asthma attacks and the pathophysiology involving immune cells like mast cells, basophils, and eosinophils. The document outlines the diagnostic approach including assessing symptoms, lung function testing, allergy testing, and trial of treatments. It also discusses managing asthma through a stepwise treatment approach based on symptom severity. Finally, it introduces several newer treatment modalities for asthma including allergen immunotherapy, anti-IgE therapy like Omalizumab, and long-acting bronchodilators.
This document discusses approaches to asthma and newer modalities in treatment. It begins by defining asthma as a chronic airway inflammation disease characterized by variable respiratory symptoms and airflow limitation. It then discusses asthma triggers and the pathophysiology involving T helper cells, cytokines, IgE, mast cells, and eosinophils. Diagnosis involves assessing symptoms, history, physical exam, pulmonary function tests, allergy testing, and response to treatment. Management follows a stepwise treatment approach adding or increasing controller medications as needed. Newer modalities discussed include allergen immunotherapy, anti-IgE therapy like omalizumab, anti-IL13 therapy, long-acting bronchodilators, and bronchial thermoplasty.
Severe or difficult-to-treat asthma affects approximately 15% of asthma patients and is characterized by persistent symptoms and exacerbations despite high-dose controller medications. These patients experience greater morbidity and increased healthcare use. Characteristics of severe asthma include irreversible airflow obstruction, neutrophilic inflammation, ongoing mediator release, and reduced association with atopy. Management involves accurate diagnosis, treatment of risk factors and comorbidities, appropriate medication including biologics like omeklizumab, and ongoing patient education and support.
Asthma is a chronic inflammatory condition associated with airway hyperresponsiveness (an exaggerated airway-narrowing response to specific triggers such as viruses, allergens and exercise).
Physiotherapy can provide relief from symptoms of uncontrolled asthma, including coughing, wheezing, tightness in the chest, shortness of breath and QOL.
This document discusses asthma, including:
- The definition of asthma as a chronic airway disease characterized by variable airflow obstruction and airway hyperresponsiveness.
- Asthma is a heterogeneous disease influenced by both genetic and environmental factors, and has a complex pathophysiology involving airway inflammation.
- Type 2 inflammation, involving cytokines like IL-4, IL-5, and IL-13, underlies many asthma phenotypes and is a target of new biologic therapies.
Asthma is the most frequent chronic illness in children and is a common noncommunicable disease (NCD) that affects both adults and children. Coughing, wheezing, chest tightness, and shortness of breath are among the symptoms. This presentation target therapies for Asthma including its clinical use, etc. For more information, please contact us: 9779030507.
This document provides information on bronchial asthma, including:
- Asthma is a chronic inflammatory airway disease characterized by wheezing, breathlessness, and coughing.
- It affects over 350 million people globally and causes nearly 400,000 deaths per year, most in developing countries.
- Long-term treatment involves inhaled corticosteroids to reduce inflammation. Other treatments include oral corticosteroids, leukotriene modifiers, and long-acting beta-2 agonists.
- Triggers include infections, allergens, exercise, air pollution, weather changes, drugs, stress, and smoking. Proper management is needed to prevent complications and control symptoms.
Bronchial Asthma is a chronic inflammatory disorder of the airways characterized by recurrent episodes of wheezing, breathlessness, chest tightness and coughing, especially at night or in the early morning. These episodes are usually associated with reversible airflow obstruction. Asthma is classified based on age of onset, triggers, and severity. The pathophysiology involves chronic airway inflammation and airway hyperresponsiveness leading to recurrent symptoms. Diagnosis is based on symptoms, examination findings, and confirmation of reversible airflow obstruction on spirometry. Treatment involves a stepwise approach using inhaled corticosteroids and bronchodilators to control symptoms and prevent exacerbations. The goals are to maintain normal lung function and activity levels while
Asthma is a chronic lung disease characterized by reversible airway obstruction and airway inflammation. It can be triggered by various environmental factors and allergens. Diagnosis involves measuring lung function through spirometry and checking for improvements after bronchodilator use. Prevention strategies aim to reduce exposure to triggers through environmental controls and allergen avoidance. Treatment follows guidelines that use medication on a stepwise basis depending on symptom severity. Despite treatment, exacerbations still occur and disproportionately impact some groups, highlighting the need for improved management across populations.
Similar to Exercise-Induced Bronchoconstriction (20)
- Cat and dog allergens such as Fel d 1 and Can f 1 are major allergens found in fur, dander, and saliva that can become airborne and cause sensitization in a large percentage of allergic individuals.
- Lipocalins make up many mammalian allergens and show cross-reactivity between species due to structural similarities, explaining co-sensitizations between cats, dogs, horses, and other animals.
- Higher levels of IgE antibodies to specific dog lipocalins are associated with more severe asthma in children with dog allergy.
1) DRESS syndrome is a severe cutaneous drug reaction characterized by fever, lymphadenopathy, hematologic abnormalities, multisystem involvement, and viral reactivation. It has a delayed onset of 2-3 weeks after starting the culprit drug.
2) The skin manifestations are typically a polymorphous maculopapular eruption and facial edema. Systemic involvement can include the liver, kidneys, lungs and other organs.
3) Diagnosis is based on clinical criteria including the RegiSCAR scoring system which evaluates morphology, timing of onset, organ involvement, hematologic abnormalities and viral reactivation.
Wheat is one of the most important global food sources and wheat allergy prevalence varies from 0.4-4% depending on age and region. Several wheat proteins have been identified as major allergens, including omega-5-gliadin, alpha-amylase inhibitors, and glutenins. Studies have found that serum testing for IgE antibodies to specific wheat allergens, such as omega-5-gliadin, glutenins, and alpha-amylase inhibitors, can help diagnose wheat allergy and distinguish between mild and severe cases. Sensitization to different wheat allergens is associated with wheat-dependent exercise-induced anaphylaxis versus occupational baker's asthma. Proper diagnosis and
Major indoor allergens include dust mites, domestic animals like cats and dogs, insects like cockroaches, mice, and fungi. Dust mites thrive in warm, humid environments like mattresses, bedding, and upholstered furniture, where they feed on human skin scales and excrete allergenic fecal particles. Cat allergens like Fel d 1 accumulate in fur and can become airborne, causing worse asthma outcomes in sensitized individuals. Minimizing exposure involves removing carpets, frequent washing of bedding, humidity control, HEPA filtration and ventilation.
This document provides information on Hymenoptera, focusing on the families Apidae and Vespidae. It discusses the epidemiology and prevalence of insect venom allergy. It also covers the taxonomy, venom composition, and clinical manifestations of common stinging insects like honeybees, hornets, wasps and yellow jackets. Key allergens are identified for different species.
- NSAIDs hypersensitivity can present with distinct clinical phenotypes based on organ system involvement and timing of symptoms. It is estimated that less than 20% of reported adverse reactions to NSAIDs are true hypersensitivities.
- AERD/NERD involves eosinophilic rhinosinusitis, asthma, and nasal polyps. Exposure to aspirin or other NSAIDs exacerbates bronchospasms and rhinitis. Management involves lifelong avoidance of culprit and cross-reacting NSAIDs.
- Various phenotypes are described beyond the EAACI classification, including blended reactions involving multiple organs, food-dependent NSAID-induced anaphylaxis, and NSAID-selective immediate reactions. Proper diagnosis relies
The document discusses food immunotherapy for treating food allergies. It provides definitions and outlines immune mechanisms and efficacy evidence from studies on peanut, cow's milk, egg, and wheat oral immunotherapy (OIT). Peanut OIT studies showed 67-78% of children achieved desensitization and 21-46% achieved sustained unresponsiveness. Cow's milk and egg OIT also demonstrated desensitization in 50-75% of children. Wheat OIT studies found 52-69% achieved desensitization. OIT was effective at increasing tolerance but also increased rates of adverse events during treatment.
This document summarizes X-linked agammaglobulinemia (XLA), an inherited primary immunodeficiency caused by mutations in the Bruton's tyrosine kinase (Btk) gene. XLA is characterized by absent B cells and low immunoglobulin levels, leading to recurrent bacterial infections starting in infancy. Management involves immunoglobulin replacement and antibiotic therapy. With treatment, life expectancy has improved dramatically though complications can include lung disease. The document also briefly discusses other forms of agammaglobulinemia caused by defects in genes important for early B cell development.
This document discusses histamine and anti-histamines. It provides information on:
1. The structure and function of histamine and its receptors in immune response regulation. Histamine plays a role in processes like antigen presentation and influencing T and B cell responses.
2. The classification and structures of different types of anti-histamines, including first and second generation anti-histamines from different chemical classes.
3. Some anti-histamines have the potential to cause hypersensitivity in rare cases, even those from different chemical classes with no structural similarity.
The document discusses beta-lactam allergy, including penicillin and cephalosporin allergies. It covers the epidemiology, classifications, structures, mechanisms, and investigations of beta-lactam allergies. Specifically, it notes that penicillin is the most commonly reported antibiotic allergy. It describes the hapten concept of small molecules like beta-lactams binding covalently to proteins to form antigen complexes. Skin testing and in vitro tests are used to investigate immediate IgE-mediated allergies, while patch testing is used for delayed reactions.
This document provides an overview of intravenous immunoglobulin (IVIG) therapy. It discusses the structure and classes of immunoglobulins, mechanisms of action including neutralization, opsonization, and modulation of immune cells. It also covers the manufacturing process, pharmacokinetics, indications for use in primary immunodeficiencies and autoimmune diseases, dosing, administration, and adverse effects. The differences between IVIG products are also reviewed.
More from Chulalongkorn Allergy and Clinical Immunology Research Group (20)
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Hiranandani Hospital in Powai, Mumbai, is a premier healthcare institution that has been serving the community with exceptional medical care since its establishment. As a part of the renowned Hiranandani Group, the hospital is committed to delivering world-class healthcare services across a wide range of specialties, including kidney transplantation. With its state-of-the-art facilities, advanced medical technology, and a team of highly skilled healthcare professionals, Hiranandani Hospital has earned a reputation as a trusted name in the healthcare industry. The hospital's patient-centric approach, coupled with its focus on innovation and excellence, ensures that patients receive the highest standard of care in a compassionate and supportive environment.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
2. Outline
•Introduction and definition
•Clinical presentation
•Pathogenesis
•Prevalence and risk factors
•Diagnosis and treatment
3. Introduction
•First described
: 150 A.D. by Aretaeus of Cappodocia
•First observed among asthma persons
: Exercise-induced asthma (EIA)
•Post-exercise asthma like symptoms in persons without asthma
: Exercise-induced bronchoconstriction (EIB)
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
4. Classification of EI-hypersensitivity syndromes
Exercise Induced
Hypersensitivity syndromes
EI-Respiratory disorders
EI-Bronchoconstriction
EI-Rhinitis
EI-Anaphylaxis
EI-Urticaria
+ Asthma
W/O Asthma
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
5. Definition of Exercise-induced bronchoconstriction (EIB)
•“Transient, reversible narrowing of the lower airways that occurs after vigorous exercise.”
–EIB with chronic asthma based on spirometry
–EIB without chronic asthma
•EIA: not used
“Exercise not induce asthma but rather a trigger of bronchoconstriction.”
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
7. Clinical presentation
•The hallmark of EIB
–Acute airflow obstruction (measured FEV1)
–Peak rapidly 3-15 minutes after exercise stop
–Remits spontaneously within 20 – 40 min
(recovery time not prolonged)
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
8. •ATYPICAL presentation
–Appear during prolonged exercise and recovery time often prolonged
–Late-phase constriction:
•4 -12 hours after exercise
•Generally less severe
•No predictors and not consistent in the same individual
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
Clinical presentation
9. Clinical symptoms in children
Most common
•Cough
•Wheezing
•Chest tightness
•Shortness of breath
•Excess mucus
Non-specific
•Poor performance
•Chest pain
•Prolonged upper respiratory illness
•Avoidance of activity
•Inability to keep up with peers
Lee So-Yeon et al, Expert Rev Clin Immunol.2009;5(2):193-207
Self reported symptoms do not significantly correlate with EIB diagnosis
10. Refractory period in EIB
“A period of diminished responsiveness when
a second period of exercise follows in 1 to 4 hours.”
•40-50% of EIB have refractory period.
•Mechanism not fully understood
–Bronchial smooth muscle tolerant to mediators
–Depletion of catecholamines
–Increased circulation of prostaglandin
–Degranulation of mast cell mediators
–PGE2 may be the important mediator in refractory period
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
11. Refractory period in EIB
E.R. McFadden Jr. Middleton's Allergy: Principles & Practice, 7th ed
15. Water loss by evaporation from the airway surface
Mucosal dehydration
Increase osmolarity
: Na+,Cl-,Ca2+ ,K+
Cell volume changes
Mediators released
Smooth muscle contraction
Vascular leakage
Edema
Mucosal cooling
Vasoconstriction
Rapid re-warming of Airway
•Reactive hyperemia
•Vascular engorgement
Vascular leakage And edema
Exercise-induced bronchoconstriction
Thermal theory
Osmotic theory
16. Disease model of exercise-induced
bronchoconstriction (EIB) pathogenesis.
T. Pongdee and J.T. Li / Ann Allergy Asthma Immunol 110 (2013) 311e315
Inflammatory cells & mediators
Neuropeptide
Epithelial
Shedding
17. Patients who are susceptible to EIB
(Asthma + Atopy +
increase exhaled FeNO)
Immunopathology of the patient at risk
Epithelial shedding
Overproduction of inflammatory mediators
Relative underproduction of protective lipid mediators
Infiltration of the airways with eosinophils and mast cells
Hallstrand TS. Curr Allergy Asthma Rep 2009; 9:18-25.
20. Hallstrand TS. Curr Allergy Asthma Rep 2009; 9:18-25.
Epithelial cells
release ATP
ATP
•key regulators of the depth of ASL layer
•via A2b receptors act on mast cells to release mediators
•Expresses 15-lipoxygenase-1
•Major source of PGE2
T. Pongdee and J.T. Li / Ann Allergy Asthma Immunol 110 (2013) 311e315.
Epithelium
21. Mast cell & Eosinophil
•Mast cells
: PGD2, LTs, histamine
•Eosinophils
: LTs, Eosinophilic cationic protein (ECP)
T. Pongdee and J.T. Li / Ann Allergy Asthma Immunol 110 (2013) 311e315
22. Sensory nerve
•Eicosanoids (CysLTs) activated sensory nerves release : Neurokinins
bronchoconstriction , mucous release
•Mucin 5AC (MUC5AC) increase in airway
: predominant gel-forming mucin of goblet cells
T. Pongdee and J.T. Li / Ann Allergy Asthma Immunol 110 (2013) 311e315
24. The concentration of
columnar epithelial cells
The concentration of
eosinophils
EIB+ EIB- EIB+ EIB-Hallstrand
et al., J Allergy Clin Immunol. 2005 September ; 116(3): 586–593.
Effects of exercise challenge on the levels of eicosanoids in
induced sputum of individuals with asthma with EIB.
25. EIB+ EIB- EIB+ EIB-The
levels of CysLTs The ratio of CysLT to PGE2
Hallstrand et al., J Allergy Clin Immunol. 2005 September ; 116(3): 586–593.
Effects of exercise challenge on the levels of eicosanoids in
induced sputum of individuals with asthma with EIB.
26. Effects of exercise challenge on the levels of mast cell mediators in induced sputum of individuals with asthma with EIB.
Histamine
Tryptase
Hallstrand et al., J Allergy Clin Immunol. 2005 September ; 116(3): 586–593.
27. Effects of exercise challenge on the levels of eicosanoids in induced sputum of individuals with asthma with EIB.
CysLT
LTB4
Hallstrand et al., J Allergy Clin Immunol. 2005 September ; 116(3): 586–593.
28. Effects of exercise challenge on the levels of eicosanoids in induced sputum of individuals with asthma with EIB.
PGE2
TXB2
Hallstrand et al., J Allergy Clin Immunol. 2005 September ; 116(3): 586–593.
29. EIB and Airway Injury in the Elite Athlete
Airway cooling
Recruitment of small airways into humidifying process
•Epithelial damage
•Loss of PGE2
Microvascular leakage
Repeated exposure to plasma products
Alters airway smooth muscle
Sensitization of airway smooth muscle
Increased response to
Acute increase of LTs, PGs
EIB
T. Pongdee and J.T. Li / Ann Allergy Asthma Immunol 110 (2013) 311e315
31. •7 – 20% in general population
•Up to 50% in competitive athletes
•EIB is reported to occur in
–up to 90% of individuals with asthma
–40% of those with allergic rhinitis
Prevalence of EIB
T. Pongdee and J.T. Li. Ann Allergy Asthma Immunol 2013;110: 311-315
32. Prevalence of EIB
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
33. Prevalence of EIB
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
34. •56 asthmatic children, 6-15 years old
•Criteria : 15% reduction in PEFR or having wheezing during exercise-challenge test was considered as having EIB.
•Prevalence of EIB was 41% (n=23)
–16/23 (69.5 %) had EIB history
–7/23 (30.4%) had no EIB history
•EIB history (p=0.021) and family history of asthma (p=0.04) correlated with EIB.
EXERCISE‐INDUCED BRONCHOCONSTRICTION IN THAI PEDIATRIC ASTHMA
Yimsuwan U, et al. JACI, Vol 219, Page AB3, Feb 2012
35. Risk factors of EIB in general
Factor
Decrease EIB/EIA
Increase EIB/EIA
Environmental conditions
•Warm temperatures (34-37° C)
•High humidity (100%)
•Low air pollution
•Absence of allergens
•Cold temperatures,
•Dry air,
•Pollutants,
•Allergens,
•Dust Irritants: smoke, automobile exhaust, sulphur dioxide, nitrogen dioxide, ozone,chlorine
Type, intensity, duration of exercise
•Short episodes
•Brief rests
•VO2 max <40% predicted,
•<3 minutes continuous exercise
•Continuous activities
•Maximum aerobic capacity VO2 max ≥60% predicted
•6-8 minutes continuous exercise
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
36. Risk factors of EIB in general
Factor
Decrease EIB/EIA
Increase EIB/EIA
Overall control of underlying asthma and BHR
•Good control: FEV1 >70% predicted
•Fall in BHR
•Poor control: FEV1 <65% predicted
•Increase in BHR
Physical conditioning
•Good conditioning
•Warm up and cool down sessions
•Poor conditioning
•Sudden burst of activity
•Emotional stress,
•Athletic overtraining
Respiratory tract infections, especially viral
•No respiratory tract infections
•Presence of respiratory tract infections,Sinusitis Rhinitis
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
37. Risk factors of EIB in general
Factor
Decrease EIB/EIA
Increase EIB/EIA
Time since last exercise (12)
•within 40-90 min may benefit from refractory period
•>2-3 hr
Concurrent medications
•Maintenance anti- inflammatory bronchodilator medication
•Salicylates
•NSAIDS
•ß-blockers
Pre-exercise foods eaten
None
•Peanuts, celery, shrimp, grain, carrots, bananas, wheat
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
39. Step for evaluation suspected EIB +/- asthma
•History
•Physical examination
•Pulmonary function test (pre/post bronchodilator)
•Diagnostic challenges
•Try treatment of EIB +/- asthma
•Further investigations
40. History suggest EIB
•Common clinical symptoms :
–coughing, wheezing, shortness of breath, excessive mucus production, chest tightness, chest pain prolonged recovery time following exercise
•Less common clinical symptoms:
–stomach pain, nausea and near-death experiences
•Symptoms relieved or prevented by SABA/LABA
AHRQ Publication No. 10-E001 ,January 2010 (Web site posting) ,Revised March 2010
41. Physical examination
•Asthma
–Co-morbid allergic disease: AR,AD
•Non-asthma
–Chronic lung disease
–Cardiovascular disease
–Obesity
–Etc.
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
42. Pulmonary function test
FEV1 <70%
•Suspected asthma
•Try treat with ICS/ LTRA
•SABA as needed
•Avoid triggers
•Repeat FEV1 after treatment
–Improve: possible EIB with asthma need objective testings
–NOT improve: other diseases
FEV1 >70%
•Suspected EIB without asthma
•Perform objective testings : one or more
–Standardized ECT
–Eucapnic Voluntary Hyperventilation (EVH)
–Mannitol test
–Sport specific field challenge test
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
43. Differential diagnosis and further investigations
Differential diagnosis
•Physiologic limitation
•VCD,EILD, EIH
•Anxiety hyperventilation syndrome
•Obesity related dyspnea
•Cardiac abnormality: IHSS, tachyarrythmia
•Pulmonary AVM.
•Other diagnosis
Further investigations
•EKG
•Echocardiogram
•Holter monitoring
•Chest x-ray
•CT, MRI
•Pulmonary exercise stress test
•Exercise rhinoscopy
•Laryngoscopy
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
44. Diagnostic challenges
•Direct Challenges : Methacholine / Histamine
•Indirect Challenges :
–Exercise Challenge test (ECT)
–Surrogate
•Eucapnic Voluntary Hyperventilation (EVH)
•Inhalation of Mannitol, Adenosine monophosphate (AMP) or hypertonic saline (4.5%NaCl)
IOC-MC recommend for elite athlete suspected EIB
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
45. Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
46. Exercise challenge test
•At 20-25°C, dry air (10 mg H2O/L) with a nose clip in place while running or cycling
% of predicted maximum HR
80-90%
mins
2-4 mins
Maintain 4-6 mins
•Stop
•Record FEV1 at 5,10,15,20,25,30 mins After exercise
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, VOL 187 ,2013
47. Lee So-Yeon et al. Expert Rev Clin Immunol. 2009;5(2):193-207.
48. Contraindications for exercise challenge
Absolute
•Severe airflow limitation (FEV1 < 50% pred/<1L)
•Heart attack/Stroke in last 3 months
•Uncontrolled hypertension (syst > 200 or diast > 100)
•Known aortic aneurysm
•Unstable cardiac ischemia or malignant arrhythmias
Relative
•Moderate airflow limitation (FEV1<60%pred or < 1.5L)
•Inability to perform acceptable quality spirometry
•Pregnancy
•Nursing mothers
•Current use of cholinesterase medication of myasthenia
The American Thoracic Society. Am J Respir Crit Care Med 2000;161:309-29
51. ECT interpretation
•The criterion for the percent fall in FEV1 used to diagnose EIB is >10 – 15 %
Severity
•> 10% but < 25% = Mild
•> 25% but < 50% = Moderate
•> 50% or > 30% in steroid treated = Severe
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, VOL 187 ,2013
52. •High sensitivity to identify EIB
•IOC MC
: optimal test to identify EIB for athletes seeking approval to inhaled β2–agonist before an event
Eucapnic Voluntary Hyperventilation (EVH)
Rundell KW, Slee JB. J Allergy Clin Immunol 2008;122:238-46.
53. Eucapnic Voluntary Hyperventilation (EVH)
•Induced high ventilation level up to 110 L/min and maintain near normal alveolar CO2
•Protocol
–Breathing dry air contained: 5%CO2 +21%O2
–Controlled ventilation rate: 60-85% of MVV*
•MVV:max.voluntary ventilation
= 21-30 times of baseline FEV1
–Consistent ventilation for 6 min
–NOT perform in subject with FEV1< 70%
•The criterion for the percent fall in FEV1 used to diagnose EIB is >10 – 15 %
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
54. Inhalation of Mannitol
•Produce hyperosmolar environment
•Protocol (Aridol approved by FDA 2010)
–Mannitol dry powder inhaler progressive doubling doses of 5,10,20,40,80,160,160 and 160mg with maximal total dose 635mg
–1 min. after each dose, FEV1 measured
–+ve test: % fall in FEV1 >15 compare to baseline
: a between dose % fall in FEV1 >10
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
55. Hypertonic saline challenge
Protocol
•Nebulize 4.5% hypertonic saline inhalation in 15- 20 minutes
•Exposure time: 30 & 60 sec, 2 & 4 & 8 min
•FEV1 measurement: 1 min after every exposure
•< 10% fall in FEV1 doubled exposure time
•> 10% fall in FEV1 same exposure
•Termination: ≥ 15% fall in FEV1 or total minimum dose of 23 g (15.5 mins)
56. Sport specific exercise challenge test
1.Natural setting athlete’s sport in field exercise
2.Simulated condition in laboratory
•Important test in sports under special environment
–Winter sport
–Swimming sport
•Low sensitivity than EVH
Weiler JM et al. Ann Allergy Asthma Immunol 2010;105:S1-S47.
60. •Response rate: 30-60% of EIB with asthma
•Degree of efficacy
: variable(complete no effect)
•Practical use
–Combination of ICS with another agents to achieve control such as SABA, LABA, LTRA
–After controlled: step down to regular use of ICS alone
Inhale corticosteroid (ICS)
61. Symptoms
First-line Therapy
Second-line Therapy
NORMAL LUNG FUNCTION (FEV1 >80%)
Rare symptoms of asthma;
mild-moderate EIB
β-Agonist or chromone
before exercise
Leukotriene modifier
2 hr before exercise
Asthma symptoms
> 2×/wk and/or moderate-severe EIB
Daily leukotriene modifier ± β-agonist before exercise
Daily ICS (low dose)
± β-agonist before exercise
Approach to Therapy in Patient with Exercise-induced Bronchoconstriction (EIB)
Teal S. Hallstrand. Middleton's Allergy: Principles & Practice, 8th ed
62. Symptoms
First-line Therapy
Second-line Therapy
REDUCED BASELINE LUNG FUNCTION (FEV1 <80%)
Asthma symptoms > 2×/wk and EIB
Daily ICS(≥ moderate dose)
± β-agonist before exercise
Add leukotriene modifier for persistent symptoms.
Avoid LABA if possible.
Approach to Therapy in Patient with Exercise-induced Bronchoconstriction (EIB)
Teal S. Hallstrand. Middleton's Allergy: Principles & Practice, 8th ed
63. An Official American Thoracic Society Clinical Practice Guideline 2013 : Exercise-induced Bronchoconstriction
Recommendation
Short-acting β2-agonist (SABA) before exercise
is typically administered
15 minutes before exercise.
strong recommendation, high-quality evidence
A mast cell stabilizing
agent before exercise
strong recommendation, high-quality evidence
Inhaled anticholinergic
agent before exercise
weak recommendation, low-quality evidence
Against administration of ICS only before exercise
strong recommendation, moderate-quality evidence
Am J Respir Crit Care Med 2013;187:1016-1027.
64. Recommendation
Daily administration of ICS
(2–4 weeks after the initiation of therapy to see maximal improvement)
strong recommendation, moderate-quality evidence
Daily administration of
a LTRA
strong recommendation, moderate-quality evidence
An Official American Thoracic Society Clinical Practice Guideline 2013 : Exercise-induced Bronchoconstriction
Am J Respir Crit Care Med 2013;187:1016-1027.
65. •For patients with EIB and allergies who continue to have symptoms despite using an inhaled SABA before exercise,or who require an inhaled SABA daily or more frequently
we suggest administration of an antihistamine
(weak recommendation, moderate-quality evidence).
•Against administration of antihistamines
in patients with EIB who do not have allergies
(strong recommendation,moderate-quality evidence).
An Official American Thoracic Society Clinical Practice Guideline 2013 : Exercise-induced Bronchoconstriction
Am J Respir Crit Care Med 2013;187:1016-1027.
66. NONPHARMACOLOGIC THERAPIES
•Pre-exercise
: Warm up 60-80% HR max X 10-15 mins
–Given bronchoprotective effect and
extended refractory period from 1 - 4 hr.
–Recommend add on pharmacotherapy better than warm up alone or SABA alone
•Post-exercise
: Warm down X 10-15 mins
Am J Respir Crit Care Med 2013;187:1016-1027.
67. •Avoidance of triggers
•Nasal breathing
•Wearing a mask in cold environments
•Avoiding exercise in conditions where air is cold and dry
•Low salt diet
•Ѡ-3 fatty acid(fish oil) and Ascorbic acid supplement
NONPHARMACOLOGIC THERAPIES
Am J Respir Crit Care Med 2013;187:1016-1027.
68. Effects of fish oil supplementation on severity of exercise-induced bronchoconstriction.
Mickleborough TD, et al. Chest 2006; 129:39-49.
69. Weiler et al, J ALLERGY CLIN IMMUNOL PRACT MAY/JUNE 2014
Symptoms suggestive of EIB and normal FEV1 (>70% of predicted)
Exercise challenge/Surrogate indirect airway challenge
Δ FEV1 post challenge > 10-15%
Consider
Alternative
diagnosis
EIB confirm
Consider treatment
Non-pharmacologic (prevent symptoms only)
•Warm-up exercise
•Face mask/scarf
•Dietary modification
Pharmacologic
Treat symptoms
: SABAs
Prevent symptoms
: SABAs 5-20 min before exercise
(consider addition of MCSA or
anticholinergic if SABA not working)
Used daily or more? : Consider addition of controller therapy (daily ICS+/-LABA, and/or LTRA; AH if allergic
No
Yes