The document discusses reactive airway disease (RAD), describing it as a condition where bronchial tubes overreact to irritants, often seen in young children before a diagnosis of asthma is made. It outlines clinical presentations, diagnostic methods, and management strategies for RAD and other related conditions such as asthma and COPD, emphasizing the importance of airflow limitation and inflammation in diagnosis. Additionally, it highlights different tests and assessments used to monitor and diagnose airway diseases.

1. Dr. Parthiv Mehta
Hon. Chief, Pulmonary- Critical Care, UNMICRC
Medical Director, Central United Hospital
Medical Director, Mission Life India
Ahmedabad - GUJARAT
parthivmehta@Hotmail.com
REACTIVE
Airway Diseases

2. Asthma
COPD
Viral
Wheeze
(Children)
Emphysema
Hyper
Ventilation
Syndrome
Infective
(bacterial)
Asthma
Allergic
Bronchopulmonary
Aspergillosis (ABPA)
Bronchiectasis
Nonsmoking
Fixed Obstruction
Obliterative
Bronchiolitis
Eosinophilic
Bronchitis
CF
Chronic
Cough
1. Wardlaw AJ et al. Clin Exp Allergy. 2005;35:1254–1262.
Spectrum of AIRWAY DISEASES

3. What is Reactive Airway Disease?
Reactive airway disease (RAD) is used to
describe different conditions.
People with RAD have bronchial tubes that
overreact to some sort of irritant.
The term is most commonly used to describe a
person who is wheezing or having a bronchial
spasm, but who has not yet been diagnosed
with asthma.

4. RAD used more often for young children, who
are younger than 5 – before stamping it as
ASTHMA!
RAD is not the same as RADS.
RADS is caused by excessive exposure to some
sort of corrosive gas, its fumes or vapours.
RADS occurs just one time and is not chronic.
What is Reactive Airway Disease?

5. RAD – Clinical Pathology
• Hyper – sensitive (Reactive)
Bronchial tubes (BHR)
• Excess mucus in the bronchial
tube
• Swollen mucous membrane in
the bronchial tube (Inflammation)
FORGET NOT, We are…
REVERSIBLE

6. RAD – Clinical Presentation
• Wheezing
• Coughing
• Shortness of breath or difficulty breathing
Remember, We are…
EPISODIC - INTERMITTENT

7. How Do I Catch RAD?

8. RAD / Asthma
Inflammation

9. Investigations for RAD / Asthma
Inflammation
1 2
3

10. Episodic Symptoms
• Skills of clinician to acquire vital information
through patient's medical history and
physical examination.

11. Episodic Symptoms
• Age of onset
• Symptom free period
• Family history
• Triggers
• Use of Relievers
• Exacerbations

12. • Most often after an infection.
• It’s caused by some irritant that triggers
the airways to overreact and swell or
narrow.
Pet hair or dander Smoke
Dust and Pollen Exercise
Perfume/Strong odours Stress
Changes in the weather Food
RAD – Pre-disposing FactorsEpisodic Symptoms - TRIGGERS

13. Episodic Symptoms
• Age of onset
• Symptom free period
• Family history
• Triggers
• Use of Relievers
• Exacerbations

14. Episodic Symptoms

15. Reversibility
• “Presence” of Airflow limitation - Obstruction
• “Variation” in Airflow
• “Improvement” upon usage of
“RELIEVERS”
Peak Flow Meter
Spirometer
Osillometer

16. Peak Flow Meter
• Peak expiratory flow (PEF), also called peak
expiratory flow rate (PEFR) is a person's
maximum speed of expiration
• Directly correlates with “available aperture”
of airway
• Measures the airflow through the bronchi
and thus the degree of obstruction in the
airways
• Effort Dependent
R e v e r s i b i l i t y

17. Peak Flow Meter
• Simple
• Handheld
• Easy to perform and interpret
• “DO IT YOURSELF”
Weighing Scale
Thermometer
Sphygmomanometer
R e v e r s i b i l i t y

18. R e v e r s i b i l i t y
• RAD / Asthma is suspected when there is >/= 20%
diurnal variation on >/= 3 days a week or for 2
weeks in a PEF
• Wide range of ‘normal' values and high degree of
variability >> Not “the recommended test” to
identify asthma
Peak Flow Meter
Good tool to MONITOR RAD/Asthma
Higher the FLOW
Lesser the SEVERITY

19. Investigations for Asthma
Inflammation
Supportive / Differentials
4

20. Spirometer

21. Spirometer
• Spirometry is a vital test to establish “Airway
Obstruction” and its “Reversibility”
objectively and accurately.
R e v e r s i b i l i t y

22. Spirometer
• Reversibility : Significant reversibility is
indicated by an increase of > 12 % and/or 200
ml in FEV1 after inhaling a short-acting B2
agonist – bronchodilator.
R e v e r s i b i l i t y

23. Spirometer
• Performing Reversibility:
– Spirometry test (with at least 2 reproducible flow
volume loops)
– Intake of a fast acting bronchodilator (often
Salbutamol) through inhalation
– 15 minutes pause
– Second (Post Bronchodilatation) Spirometry test
(with at least 2 reproducible flow volume loops)
R e v e r s i b i l i t y

24. • Impulse Osillometery:
– Conventional Spirometry: Effort Dependent
Spirometer

25. • Impulse Osillometery (IOS): Very
useful for diagnosis of RAD /
Asthma, especially in children
where dependency of Spirometry
and flow volume loop is
questionable.
– IOS uses small amplitude pressure
oscillations to determine the
resistance of the airway.
– It is largely independent of effort
does not require coordination, but
does require cooperation of patient.
Spirometer
Episodic Symptoms

26. Inflammation
• Inflammation in airways is MUST to confirm
RAD / Asthma.
• Airways – Upper and Lower
• Eosinophilic >> Neutrophilic
• Modalities:
– Direct: Sputum - Eosinophilia
– Indirect: Markers - Exhaled NO, ECP, EPX

27. Sputum
• Sputum is induced by
proper coughing or using
inhalations of 3% of
hypertonic saline.
• Sample: should look
more opaque and/or
dense and unlike saliva.
• Cell differential counts
are performed.
Inflammation

28. Sputum
• Eosinophilia in sputum:
Directly linked with the
underlying eosinophilic
airway inflammation.
Management employing
sputum monitoring has
been found useful in
preventing exacerbations
and hospitalizations.
Inflammation

29. Exhaled Nitric Oxide
• Nitric Oxide (NO) is produced in discrete
concentrations in the healthy human airway
(Respiratory epithelium, Nose, upper and lower
airways) where it is important in physiological
functions such as maintaining airway patency.
• It is responsible for airway inflammation and is also
the product of airway inflammation. So, Evaluation
of NO as “Surrogate marker of Eosinophilic
Inflammation” is gaining acceptance.
Inflammation

30. Exhaled Nitric Oxide
• Nitric oxide analyzers are used to measure
exhaled nitric oxide (FENO).
Inflammation

31. Exhaled Nitric Oxide
• NO is over produced in asthmatic individuals.
• Potential of FENO to predict exacerbations of
asthma has been examined in various studies
and levels were found to be elevated before the
fall in lung functions or the development of
clinical symptoms of asthma exacerbations.
• NO is increased in inflammation of lung e.g.
asthma. If bronchospasm without inflammation,
NO is not increased i.e. it is not Asthma.
Inflammation

32. Exhaled Nitric Oxide
• Ingestion of foods containing nitrates,
smoking status, ambient nitric oxide level,
nasopharyngeal contamination, airway
infections and drugs such as leukotriene
modifiers may affect the actual collection
and quantification of exhaled nitric oxide.
• Patients are asked to take nothing by mouth
for one hour before sample collection.
Inflammation

33. Markers of Inflammation
• Important especially for diagnosis of Asthma in
Children
• Currently, the noninvasive clinical assessment of
airway inflammation in young children is
limited.
• The detection of raised blood eosinophil levels
or evidence of eosinophil activation proteins in
blood or urine, such as Eosinophil Cationic
Protein (ECP) or Eosinophil Protein X (EPX), can
be used in addition to the examination of
nasopharyngeal secretions.
Inflammation

34. Markers of Inflammation
• In the near future it is likely that tidal
breathing methods for measuring exhaled
nitric oxide (NO) and other gases will be
validated for use in the younger children.
• The analysis of other constituents of breath,
such as exhaled proteins, is currently being
investigated as potential indicators of airway
pathology.
Inflammation

35. Supportive / Differentials
• Allergy test
• Blood test
• Radiology: Chest X-Ray, CT Scan
• Endoscopy: Upper-Lower Respiratory, Upper GI
• 2D Echo

36. Allergy Test
• Allergy test :
– This test is to look for the trigger factors causing
asthma.
– Useful to diagnose occupational asthma and
seasonal asthma by detecting the triggers causing
the attack.
– Supports diagnosis of Asthma
– Identification of allergen triggers can assist in
formulating an avoidance strategy.
– A trial of allergen avoidance may be diagnostic and
therapeutic.
Supportive / Differentials

37. • Skin tests:
– Main tool in diagnosing allergies all over the
world
– Different allergy profile can be known by the skin
allergy tests.
• Patch test (used mainly for diagnosing contact
dermatitis)
• Scratch test
• Skin prick test
• Intradermal test
• Skin end point titration
• Parasite- kustner test (Passive transfer test).
Allergy Test
Supportive / Differentials

38. • Mechanism of skin allergy testing:
– Cells and antibodies responsible for allergies are
present under the skin as well as other parts of
the body.
– If an allergen to which patient is allergic is
applied to the skin a reaction occur and a wheal
is formed.
– The size of the wheal is measured to grade the
severity of allergy.
Allergy Test
Supportive / Differentials

39. • RAST (Radio allegro sorbent technique):
– Detects allergen specific IgE in serum.
– The results of the tests correlate well with the
skin allergy tests.
– One sample of the serum can be used to test
many allergens.
– Benefits: can be used where the skin allergy tests
cannot be performed like young children, severe
atopic dermatitis, dermatographism, history of
extreme sensitivity, patients afraid of multiple
injections.
Allergy Test
Supportive / Differentials
RAST is not influenced by drugs while skin tests are
suppressed by anti allergic drugs and steroids.
There is no risk of anaphylaxis with RAST.

40. • X-Ray Chest :
– Preferred for routine evaluation
– Helps to establish other diagnosis
• Eosinophilic Lung Disease
• Churg Strauss Syndrome
• Cystic Bronchiectasis
• Interstitial Lung Disease
• Congestive Cardiac failure
– Must for Exacerbation or Uncontrolled
• Consolidation
• Pneumothorax
Radio-Diagnostics
Supportive / Differentials

41. • CT Scan:
– Useful tool for differentiating other “asthma
alike” or co-existing morbidities for “non-
responders”.
– Role of CT scan has been established
• with suspicion of bronchiectasis
• occupational asthma
• parenchymal infiltrates
• suspicion of Allergic Bronchopulmonary Aspergillosis
and/or invasive aspergillosis
Radio-Diagnostics
Supportive / Differentials

42. • CT Scan:
Bronchial wall thickening Bronchiectasis / Bronchial dilatation
Radio-Diagnostics
Bronchial wall thickening Bronchiectasis / Bronchial dilatation
Supportive / Differentials

43. • Laryngoscopy and Bronchoscopy:
Inspection: Allows visual inspection of the upper and
lower airway.
– Help to rule out Vocal cord dysfunction, Laryngomalacia
or Tracheomalacia as an important differential diagnosis
Lavage: Broncho Alveolar Lavage (BAL) is an
important investigation for differentiation of infection
and inflammation.
Biopsy: Performing Endo-Bronchial biopsy (EBLB) or
Trans-Bronchial biopsy (TBLB)
– Will help to establish type of inflammation in airway,
parenchymal infiltration and infection as well as
structural changes in parenchyma. ABPA v/s Invasive
Aspergillosis, DILD
Endoscopy
Supportive / Differentials

44. Normal Abnormal
Laryngomalacia Tracheomalacia
Endoscopy
Supportive / Differentials
Nearly 20% of patients with refractory asthma referred for
tertiary care have coexisting VCD.
Medical utilization is higher in patients with VCD compared
with age/sex-matched asthma patients.

45. • Upper GI Scopy:
– Gastro-oesophageal reflux (GERD) is common in
patients of chronic or “difficult” asthma – nearly
twice to normal individuals.
– Though it is hard to identify potential responders
amongst asthmatics having GERD and treatment
often has little effect on asthma symptoms, it is
important to diagnose GERD.
Endoscopy
Supportive / Differentials

46. • Echocardiogram:
– 2D Echocardiogram is important to differentiate
“Cardiac Asthma” i.e. with Cardiac causes like
Left Ventricular dysfunction or pericardial
effusion from “Bronchial Asthma”.
– An effective tool to provide appropriate support
in the form of anti-failure therapy.
– Patients with COPD shall develop Cor-Pulmonale
on long run.
Echo Cardiogram
Supportive / Differentials

47. RAD / Asthma Algorithm

49. Criteria for the diagnosis of
RAD / Asthma
• Demonstration of obstruction (FEV1/VC < 70%) and FEV1 increase
by >15% (at least 200 ml) with respect to the initial value,
measured at least 15 min after the inhalation of four puffs of a
short-acting beta2 agonist agent, e.g., 400 µg of Salbutamol
• Or: FEV1 worsening by >15% during, or within 30 minutes after,
physical exercise (exertional asthma), possibly with an increase of
the specific airway resistance by at least 150%
• Or: FEV1 improvement by >15% (or by at least 200 ml, if the initial
value is below 1300 ml), after daily high-dose administration of an
inhaled corticosteroid (ICS) for a maximum of four weeks
• Or: in patients with normal pulmonary function despite a typical
history for asthma, demonstration of non-specific bronchial
hyper-reactivity by means of a standardized, multilevel
inhalational provocative test and of a more than 20% circadian
variation in PEF with measurements taken over 3 to 14 days

50. THANK YOU…..
RAD Specialist