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Asthma increased responsiveness of responsiveness of resp mm to various stimuli, narrowing of airways.

Narrowing may resolve spontaneously or with medical intervention

Status asthmaticus is a severe asthma attack which does not respond to medical intervention (EMERGENCY need to be ventilated)

Diagnosis (Dx) PFT spirometry Variable wheeze, chest tightness, coughing and breathlessness Look for decreased FEV1 Classification Atopic (allergic) o IgE levels increased o Specific IgE antibody increased, response to inhaled allergen o Skin tests with allergen returns positive o Possible family link o Extrinsic Inhaled allergens likely to provoke symptoms Any age Non-atopic (non-allergic) o Not raised o Not raised in response to inhaled allergen o Skin test with allergen returns negative o Less likely to be family linked o Intrinsic Inhaled allergens unlikely to provoke symptoms Late onset Exercised induced Asthma (EIA) Provoked by exercise, Dx by exercise challenge test Symptoms of EIA usually develop 2-10min after exercise has creased If PEFR is greater 15% post exercise period. Therefore, they have asthma Bronchoconstriction usually reverses spontaneously and airflow returns to pre-exercise levels after approx. 1 hr Pathology Characteristics pathological features o Presence in airway of inflammatory cells o Epithelial disruption o Muscousal oedema o Smooth mm spasm and hypertrophy o Mucus plugging o Impaired mucocillary function Triggers of asthma Food Environment (dust, dust-mite, pollen) Drugs Exercise Stress /emotion Overuse of antibiotics

+ Mechanism An asthma attack as an early or late phase Early phase o Severe bronchospasm Late phase o Mucous production and airway obstruction EARLY PHASE OF ASTHMA

ALLERGEN

ALLERGEN

T-Lymphocytes

B-Lymphocytes

produce IgE

once specific IgE produced it adheres to the mast cell for recurrent exposure

MAST CELLS (degranulation)

MEDIATORS released

c. AMP

(cyclic adenosine monophosphate) c.AMP = b constriction c. AMP = b dilation

affects B2 receptors of the bronchial smooth muscle

BRONCHOSPASM

+ Late phase (if not relieved by bronchodilator) After 6 hours, still circulating levels of IgE and Bronchospasm may or may not have resolved Late phase include production of eosinophils into the airways cytotoxic substances local inflammation and obstruction block small airways mucus plugging atelectasis lobar collapse hyperinflation

EARLY PHASE ( INFLAMMATION ) Allergen Mast cells Mediators

Smooth muscle bronchospasm

Airways diameter

Obstruction of small airways

Inflammation and SECRETIONS

Eosinophil infiltration

LATE PHASE
Clinical features Acute o sudden or over hrs/days o SOB o WOB o Wheeze o Complain of being unable to catch breath or breathe out o Adopts breathless position o Acc mm use (esp SCM, trap and scalenes) o May PLB (pursed lipped breathing to decrease breathlessness) o Pale, sweaty, tremor o Rapid HR, PR, and increase in BP o If resp mm cannot develop adequate pressure then PaO2 de o increases, and PaCO2 increases

Medication relievers (immediate) o metre dose inhaler: need spacer so it increase space for medicine particles to mix with air so it goes into lungs o B2 agonist (short acting) o Eg ventolin (act fast on bronchial smooth muscle) symptom controllers (over long periods of time) preventers Mx (6 steps) Step 1 assess asthma severity o Individualise treatment o Assessed when the patient is stable Step 2 achieve best lung function o Obtain maximal reversal of airway inflammation and obstruction o For adults, corticosteroids should be used to prevent inflammation Step 3 maintain best lung function, identify and avoid triggers o Trigger factors may be allergic or non-allergic o Avoiding triggers may improve asthma Step 4 maintain best lung function with optimal medication o Progress aims to relieve symptoms + use minimum maintenance doses Step 5 develops an action plan o To recognise deterioration promptly and respond appropriately o Action plan will prevent delayed initiation of preventer dose increases, prolonged exacerbations, adverse effects and reduce use of healthcare services Step 6 educate and review regularly o Educate regarding drugs o Begin at the time of diagnosis o Education needs to be individualised PHYSIOTHERAPY Mx You will commonly see patients who have asthma as a co-morbidity or, you may be asked to see a patient who has asthma in any stage of the disease It is imperative that the patient be accurately assessed and a problem list formulated.

ACUTE PHASE The main problem in an acute attack is bronchospasm. EXAMINATION Audible wheeze Wheeze on auscultation SOB (may be severe) Hyperinflated short inspiration long expiration TREATMENT Broncholdilators O2

Positioning , PLB, Breathing control

As above, relaxation, massage

LATE PHASE Later in an attack, secretions and obstruction from mucous plugging are more common. Secretions EXAMINATION +/- sputum (may be plugs) cough, paroxysmal crackles, wheezes may see segmental collapse on CXR Mucous Plugging localised wheeze on ausc BS distal to plug Careful manual techniques, positioning, mobilization Rx as appropriate to the problem TREATMENT Medication, humidification, positioning, ACBT, FET, careful manual techniques