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Bronchial Asthma II
Clinical Features & Investigations
Differential Diagnoses
Introduction
• Bronchial asthma is one of the most common
chronic illnesses and prevalence is increasing.
• Asthma is probably not one illness, but a
syndrome.
• The disease has different phenotypes with
respect to its course and prognosis and its
association with atopy.
• The diagnosis, assessment of severity and
monitoring of the effects of therapy are
more difficult in young children because it
may not be possible to obtain reliable
objective measurement of airway
obstruction.
Definitions
Bronchial Asthma:
Asthma is a chronic inflammatory disorder of the
airway in which many cellular elements play a role.
FEV1/FVC=75%
• Environmental factors
Risk Factors (contd.)
• Host factor
Twins study: effect of genetic factors about 35 to 70%
• Air pollution
• Inciters (Triggers)
Pathogenesis
• Chronic Eosinophilic Inflammation
• CD4+ TH2 Lymphocytes
• Interleukins
• IgE antibodies (Allergen specific)
• Mast Cell (and other effector cells)
• Sensitization
• Early response
• Late response
Pathogenesis (contd.)
The Allergic Cascade
Sensitization
• CD4+ Th2 cells and B cells interact and produce allergen
specific IgE
Breathlessness
Clinical Features (contd.)
• Repeated wheeze
b) Laboratory evaluation
*Full blood count and absolute eosinophil count,
*Specific IgE antibody measurements:
-In vivo i.e., skin prick tests,
-In vitro i.e., radioallergosorbent test (RAST)
c) Chest radiography.
Differential diagnoses
Differential diagnosis of wheezing during early
life
Very common
Asthma
Viral bronchiolitis
Common
Foreign body in trachea or bronchus
Endobronchial tuberculosis(TB)
Enlarged TB nodes
Differential diagnoses contd.
Uncommon
Vascular rings
Bronchiectasis
Laryngotracheomalacia
Chlamydia trachomatis infection
Obliterative bronchiolitis
Bronchopulmonary dysplasia
Aspiration from swallowing mechanism dysfunction
or cardioesophageal reflux
Differential Diagnoses contd.
Rare
Tumour
Laryngeal webs
Tracheostenosis or bronchiostenosis
Alpha-1-antitrypsin deficiency
Cystic fibrosis
Bronchial Asthma (III)
• Management
Therapy
• Acute therapy
• Short History
• Assess severity
• Tachypnoea
• Tachycardia
Classification of Acute exacerbation of
Bronchial Asthma (contd.)
Life threatening features
• Cyanosis, a silent chest, or poor
respiratory effort
• Fatigue or exhaustion
• Mild/Moderate/Severe
Moderate acute exacerbation
*Inhaled or nebulized beta2 agonist(3ce in 1 hr,
and every hr after)
If no response
• Admit ICU
The very severe asthma attack
• Ipratropium bromide
CORTICOSTEROIDS
• Should be individualized
Follow-up
• Very useful
NEDOCROMIL AND CROMOLYN
• Useful
ORAL THEOPHYLLINE
• Mild persistent
• Moderate persistent
• Severe persistent
Table: Classification of Severity for
Long Term Management
PREVENTERS CONTROLLERS RELIEVERS
(Anti-inflammatory action Sustained bronchodilator quick relief of symptoms
to prevent asthma action but weak or
and for use in acute
attacks) unproven anti-
attacks as PRN dosage
inflammatory action.
only
Inhaled corticosteroids Long-acting β2 agonists Short-acting β2
Beclomethasone, 1)Salmeterol agonists
budesonide, fluticasone, Salbutamol, terbutaline,
flunisolide, triamcinolone fenoterol etc
2)Formoterol
• EDUCATION
• Sensitization to HDM and consumption of diets with a low omega-3 to -6 fatty acid ratio have been linked to
asthma. Guy et al studied 616 children who were randomized to receive HDM avoidance, a diet with an increased
omega-3 to -6 fatty acid ratio, both interventions, or no intervention during the first 5 years of life. Of these
children, 516 were available for evaluation at 5 years.
• The HDM avoidance measure involved the use of allergen-impermeable linens and regular washing with an anti-
HDM detergent. With the diet intervention, parents were encouraged to prepare their child's meals using canola-
based oils and tuna oil capsules to achieve a high omega-3 to -6 fatty acid ratio.
• Although HDM avoidance measure reduced bedding allergen levels by 61%, it had no effect on the occurrence of
asthma, wheeze, or atopy. In fact, eczema was actually more common in the HDM avoidance group than in
controls: 26% vs. 19%.
• Similarly, while the diet intervention did succeed in increasing the omega-3 to -6 fatty acid ratio, it did not prevent
asthma, wheezing, eczema, or atopy.
• Despite the null findings of the present study, previous reports support the view that, under certain circumstances,
asthma can be prevented. However, the most effective, practical forms of early life environmental modification and
the circumstances under which it will be appropriate to implement them remain to be established.
.
Newer therapy of chronic asthma