ASTHMA

Definition: Asthma is chronic inflammatory condition of lung airways resulting in episodic

airflow obstruction. This chronic inflammation heightens the hyper responsiveness of airways
to provocative exposures.

Asthma management is aimed at Reducing airways inflammation, using CONTROLLER anti-

inflammatory medications and controlling co-morbid conditions. Less inflammation means
better asthma control and fewer exacerbations with decreased need for Quick Reliever
medications.

Etiology: Combination of environmental exposures and inherent biological and genetic

vulnerability of airways causes Asthma.

Genetics: More than 22 loci on 15 autosomal chromosomes have been linked to asthma. (IL)-4
gene on chromosome 5 and (IL)-12 on chromosome 5q31 are identified.

Environmental factors: Recurrent wheezing episodes in early childhood are associated with
common resp viruses, including respsyncytial virus, rhino virus, influenza virus, parainfluenza
virus and human meta-pneumovirus. Pneumonia or bronchiolitis requiring hospitalizations are
risk factors for persistent asthma in childhood.

Elimination of offending allergens can lead to resolution of asthma symptoms and can
sometimes cure asthma. Aggravating factors like tobacco smoke, air pollutants like ozone and
sulfur die oxide increase asthma severity. Cold dry air and strong odor can trigger broncho-
constriction when airways are irritated, but do not worsen the airways inflammation.

Epidemiology:

 In United States, childhood asthma is most common cause of childhood emergency

department visits, hospitalizations and missed school days. Annually accounting for
867000 emergency visits, 166000 hospitalization visits and 10.1 million school days lost.
 According to National centre for Health Statistic in 200, 8.9 million children have been
diagnosed with asthma in their lifetime.
 4.2 million children had asthma attack in preceding 12 months.
 Prevalence: boys 14% versus girls 10%. Poor children 16% versus affluent children 10%
 There is an increase in asthma prevalence of about 50% in every decade.
 Childhood asthma seems particularly common in modern metropolitan localities and is
strongly linked with other allergic conditions. In contrast children living in rural area in
developing countries and forming communities are less likely to develop asthma and
allergy.

80% of all asthmatics report onset of disease prior to 6 years of age. Off all young children
having recurrent wheezing, only a minority will go on to have a persistent asthma in later
childhood.

Asthma predictive index:

Major criteria: Minor criteria:

 Parent asthma  Allergic rhinitis
 Eczema  Wheezing apart from colds
 Inhalant allergen sensitization  Eosinophilis ≥ 4%
 Food allergen sensitization

Asthma triggers

Common viral infections of respiratory tract

Aero allergens in sensitized asthmatics Occupational exposures

 Animal dander  Farm and barn exposures
 Indoor allergens: Dust mite,  Formaldehyde, cedar, paint fumes
Cockroaches, Molds
 Seasonal aeroallergens: pollens and Cold air, dry air
seasonal molds Exercise
Crying, laughing , hyperventilation

Environmental tobacco smoke Co-morbid conditions

 Air pollutants: ozone, sulfur dioxide,  Rhinitis
particulate matter, wood or coal  Sinusitis
smoke, dust, endo-toxins, myco-  Gastro esophageal reflux
toxins
 Strong or noxious odor or fumes:
perfumes, hair sprays, cleaning
agents
Types of childhood Asthma:

 Recurrent wheezing in early childhood

 Chronic asthma associated with allergy that persists into later childhood and often
adulthood
 Asthma in obese females at early puberty

Clinical manifestations:
 Intermittent dry cough and expiratory wheezing
 Older children will report shortness in breath and tightness in the chest
 Younger children will report intermittent non-focal chest pain
 Respiratory symptoms can be worse at night
 Daytime symptoms often linked with physical activity or play
 Other symptoms: general fatigue, limitation of activity
 Children commonly present with cough and wheezing
 Some present with dry persistent cough
 Chest examination is often normal
 Deeper breaths can elicit wheezing
 Quick resolution of symptoms and signs after administration of short acting inhaled
beta-agonist (SABA) is supportive of diagnostic of asthma
 During ex-acerbation expiratory wheeze and prolonged expiratory phase can be
appreciated
 In severe ex-acerbations, labored breathing and respiratory distress is manifested
 There can be expiratory and inspiratory wheezing, poor air entry, supra-sternal and inter
costal retractions, nasal flaring
 In extremes air flow can be so limited that wheezing cannot be heard

Differential diagnosis
 Rhino-sinusitis
 GER (gastro esophageal reflux)
 These conditions if not specifically treated, make asthma difficult to manage
 Recurrent aspirations
 Trachea malacia
 Foreign body
 Cystic fibrosis
 Bronco pulmonary dysplasia
 Vocal cord dysplasia
  Pulmonary parasitic infections
 Tuberculosis
 Congenital heart failure
 Mass lesions compressing larynx, trachea or bronchi

Laboratory findings
Lung function tests can help confirm the diagonisis of asthma and determine the severity of
disease.

Pulmonary function testing: Spirometric is helpful in children more than 6 years of age. If on
three attempts the FEV 1 is within 5 % then the highest FEV 1 effort of the 3 is used. This
indicates effort dependence of reliable spirometric testing.

 FEV1/ FEC ratio < 0.80 indicates significant airflow obstruction

 Bronco dilator response to inhaled beta agonist is greater in asthmatics versus non-
asthimatics
 An improvement in FEV1 ≥ 10% is consistent with asthma

Peak expiratory flow

PEF 20% is consistent with asthma

Radiology

Chest x-rays often appear normal or show some hyper inflation (flattening of diaphragms)
and peri bronchial thickening

Check xrays help in identifying asthma masqueraders and complications of asthma like
pnemophorax, pnemo media sterum, atilactasis. CT scan of check is helpful in diagnosis of
custic fibrosis, aspergylosis and cilliary dis chinazia.

Allergy testing is helpful in the management and prognosis of asthma.